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RC295  .T72  Scrofula  and  its  gla 


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^YtrsX^GiUYfiW) 


SCROFULA 


ITS     GLAND     DISEASES 


AN  INTRODUCTION  TO  THE  GENERAL  PA  THOLOGV  OP 

SCROFULA,   WITH  AN  ACCOUNT  OF  THE  HISTOLOGY,  DIAGNOSIS 

AND  TREA  TMENT  OF  ITS  GLANDULAR  AFFECTIONS 


FREDERICK  TREVES,  F.R.C.S.  Eng. 

ASSISTANT-SURGEON   TO,    AND   SENIOR   DEMONSTRATOR   OF  ANATOMY    AT,   THE 

LONDON    HOSPITAL:    LATE   WILSON   PROFESSOR   OF   PATHOLOGY 

AT  THE  R.IYAL   COLLEGE  OK  SURGEONS 


NEW  YORK : 
BERMINGHAM  &  CO.,  UNION  SQUARE. 


W.  L.  Mekshon  &  Co., 

Winters,  Eiectrotypers  and  Binders, 
Rahway,  W.  J. 


PREFACE. 


I  BELIEVE  I  am  correct  in  stating  that  no  special  work 
on  the  subject  of  the  general  pathology  of  scrofula  has 
appeared  in  the  English  language  since  the  publication 
of  the  works  of  Benjamin  Phillips,  and  Robert  Glover 
in  the  year  1846,  and  no  work  on  the  subject  of  scrofu- 
lous gland  disease  since  the  appearance  of  Dr.  Price's 
monograph  in  1861.  It  must,  at  the  same  time,  be 
allowed  that  scrofula  is  a  disease  of  some  importance,  if 
on  no  other  grounds  than  those  of  its  frequent  occurence 
and  extensive  distribution,  and  that  the  glandular 
disorders  of  the  malady  form  one  of  the  most  common 
and  most  troublesome  affections  that  come  under  the 
notice  of  the  surgeon. 

These  two  facts  I  offer  as  some  reason  for  the  appear- 
ance of  this  book  at  the  present  time. 

The  works  of  Phillips  and  Glover — admirable  though 
they  are — were  not  final  as  regards  our  knowledge  of 
strumous  processes.  Since  their  publication  immense 
progress  has  been  made  in  pathological  science,  a  revo- 
lution has  been  effected  in  the  matter  of  microscopic 
research,  and  vast  additions  have  been  made  to  our 
clinical  knowledge  and  our  acquaintance  with  the  life 
history  of  disease.  In  this  progress  and  improvement 
scrofula  has  had  but  a  somewhat  niggardly  share,  and 


Vi  PREFACE. 

the  malady,  so  far  as  the  literature  of  this  country  can 
show  us,  would  appear  to  have  been  almost  ignored,  or 
dealt  with  only  in  a  fragmentary  manner.  Among 
Continental  surgeons  and  pathologists,  however,  the 
subject  of  scrofulosis  has,  of  late  years,  received  more 
manifest  attention,  with  the  result  that  the  pathology 
of  the  disease  has  been  almost  reconstructed,  its  clinical 
outline  more  acutely  denned,  and  a  more  distinct 
individuality  given  to  the  whole  disease. 

In  the  present  volume  I  have  made  extensive  use  of 
the  valuable  material  thus  provided  by  the  schools  of 
Germany  and  France.  I  have  endeavoured  to  give 
account  of  the  most  recent  facts  that  have  been  brought 
forward  in  connection  with  this  wide-spread  affection, 
and  the  most  recent  theories  that  have  been  expressed 
as  to  its  nature  and  relationships. 

At  the  same  time  I  must,  in  justice  to  myself,  remark 
that  the  greater  part  of  the  material  in  this  volume  is 
the  result  of  my  own  investigations  into  this  disease. 
The  clinical  facts  I  have  detailed  are  drawn  from  a  care- 
ful examination  of  a  very  large  number  of  scrofulous 
persons,  and  in  such  examination  I  have  endeavoured 
to  proceed  free  from  the  bias  of  any  preconceived  ideas. 
The  opinions  also  that  I  have  expressed  as  to  the 
pathological  bases  of  struma  are,  for  the  most  part, 
founded  upon  my  own  observations  ;  and  in  the  obtain- 
ing of  material  for  such  observations  I  have  been  very- 
fortunate.  The  account  given  of  the  minute  changes  in 
the  glandular  affections  is  based  upon  an  examination 
of  a  great  number  of  glands  in  various  conditions, 
obtained  from  more  than  twenty  patients,  who,  I  think, 
collectively  exhibited  every  aspect  of  the  strumous  pro- 
cess. Upon  the  matter  of  the  treatment  of  scrofulous 
gland  tumors  I   have    bestowed  much  attention,   and 


PREFACE.  V11 

hope  that  my  contributions  to  this  branch  of  practical 
surgery  will  prove  of  some  substantial  value.  The 
treatment  of  strumous  gland  affections  is  apt  to  be  a 
little  empirical,  a  little  too  exclusive,  and,  as  a  rule,  very 
regardless  of  the  fact  that  one  favorite  plan  of  treatment 
is  not  necssarily  suitable  for  every  phase  and  condition 
of  a  many-sided  disease. 

I  must  express  my  obligations  to  Dr.  T.  Smith  Rovve, 
Mr.  W.  H.  Thornton,  and  Mr.  W.  Knight  Treves,  the 
surgeons  to  the  National  Hospital  for  Scrofula  at 
Margate  (where  I  was  for  some  time  resident  assistant), 
for  permission  to  make  use  of  the  records  of  that 
Institution. 


FREDERICK  TREVES. 


18  Gordon  Square  : 
November  1881. 


CONTENTS. 


PART    I. 


THE  GENERAL  PATHOLOGY  OF  SCROFULA. 

CHAP.  PAGE 

I.  Introductory..       .        .         .        .        .         .        .        .it 

II.  Scrofula  and  Tubercle        ......       14 

III.  The  Nature  of  Tubercle    ......       29 

IV.  The  Inoculability  of  Tubercle 34 

V.     A  Definition  of  Scrofula 40 

VI,     Scrofula  and  Phthisis,  and  the  Antagonism  between 

Scrofulous  Diseases 50 

VII.     Scrofula  and  Acute  Miliary  Tuberculosis.         .         .  62 

VIII.     The  Etiology  of  Scrofula 64 

IX.     The  Scrofulous  Individual 79 


PART   II. 

SCROFULOUS  AFFECTIONS  OF  THE  EXTERNAL 
L  YMPHA  TIC  GLANDS. 

"  A  Scrofulous  Gland  " no 

'..    An  Outline  of  the  Anatomy  of  the  External  Lym- 
phatic Glands in 


x  CONTENTS. 

CHAP.  PAGE 

XI.  The  Etiology  of  Scrofulous  Lymphatic  Glands        .  116 

XII.  The  Pathology  of  Scrofulous  Lymphatic  Glands     .  126 

XIII.  Symptoms  and   Diagnosis  of    Scrofulous  Lymphatic 

Glands 145 

XIV.  The  Treatment  of  Scrofulous  Lymphatic  Glands     .  159 


SCROFULOUS   LYMPHATIC   GLANDS. 


PART    I. 

THE  GENERAL  PATHOLOGY  OF    SCROFULA. 


CHAPTER  I. 

INTRODUCTORY. 

It  must  be  confessed  that  the  pathology  of  scrofula 
is  still  very  ill-defined.  Our  present  knowledge  of  the 
disease  is  encumbered  with  the  unwholesome  remains  of 
some  centuries  of  vexed  discussion.  Since  the  earliest 
days  of  medicine  vague  ideas  and  conflicting  views 
appear  to  have  been  bestowed  upon  this  disease  from 
time  to  time,  until  they  have  at  last  formed  for  it  a  kind 
of  hereditary  property  that  has  slowly  accumulated,  and 
has  been  handed  down  to  the  present  age  with  the  pre- 
ciseness  of  entail.  Thus  it  happens  that  the  scientific 
limits  and  outlines  of  the  disease,  called  scrofula,  are 
blurred  and  indistinct.  Its  proper  position  in  the  path- 
ological scale  is  disputed  and  uncertain.  Its  relation  to 
other  morbid  states  is  variously  expressed ;  and  so 
broken  up  are  opinions  as  to  its  nature  that,  unless  a 
precise  definition  be  given,  the  term  "  scrofula  "  becomes 
almost  an  untranslatable  word,  having  a  meaning  only 
for  the  individual  who  uses  it.  To  what  varied  condi- 
tions of  health  and  to  what  different  individuals  does  the 
term  "  a  strumous  child  "  apply  !  How  little  some  sur- 
geons mean  by  the  term,  and  how  much  is  implied  by 
its  use  by  others  !  And  when  we  come  to  that  nebu- 
lous person  described  by  the  term  "  slightly  strumous," 
or  alluded  to  as  possessing  "  a  touch  of  scrofula,"  a 
sense  of  utter  vacuity  is  engendered  which  is  almost 

ii 


12  INTRODUCTORY. 

beyond  the  reach  of  scientific  relief.  No  one  would 
think  of  alluding  to  a  "  slightly  cancerous  person." 
Cancer  exists  in  a  patient  or  it  exists  not.  It  happens  to 
be  a  distinct  disease,  and  the  term  "  slightly  cancerous  " 
would  for  that  reason  be  ridiculous.  Yet  the  "  slightly 
strumous  "  are  often  before  us,  and  they  afford  no  slight 
indication  of  what  clearness  attaches  to  our  present 
knowledge  of  the  disease. 

This  lack  of  scientific  limitation  in  the  pathology  of 
scrofula,  and  this  cumbrous  heritage  of  opposed  opinions 
and  diverse  theories,  appear  to  me  to  be  to  a  great  extent 
due  to  two  causes,  I.  The  difficulty  of  isolating  scrofu- 
lous disease  from  the  manifestations  of  mere  ill-health, 
mere  frailty  of  constitution.  2.  The  persistent  attempt 
of  most  pathologists  to  find  out  some  characteristic 
anatomical  element,  for  every  disease  or  diathesis  they 
deal  with,  and  not  to  remain  satisfied  until  they  have 
found  such  specific  element.  The  first  difficulty  is  purely 
clinical,  the  second  has  reference  to  pathological  histo- 
logy. 

I.  With  regard  to  the  clinical  difficulty  it  must  be 
remembered  that  there  is  still  a  wide  area  in  medicine 
occupied  by  a  class  of  unhealthy  persons,  whose  morbid 
state  is  no  more  definitely  expressed  than  by  saying  that 
they  are  delicate,  of  feeble  constitution,  of  frail  health. 
As  knowledge  advances  this  area  becomes  more  and 
more  limited.  Indeed,  it  exists  but  as  an  evidence  of 
imperfect  knowledge  and  of  indistinct  notions  of  morbid 
change.  This  condition,  known  merely  as  the  condition 
of  delicate  health,  is  a  blank  in  medicine ;  a  state  of 
disease  without  a  pathology  and  without  any  scientific 
position.  As  our  acquaintance  with  disease  increases, 
first  one  portion  and  then  another  of  this  common  and 
untenanted  ground  is  absorbed,  now  by  one  affection, 
now  by  another.  Some  children  once  classed  with  the 
simply  delicate  are  now  perhaps  known  to  be  the  subjects 
of  hereditary  syphilis,  of  ill-defined  rickets,  or  of  some 
hereditary  conditions  that  have  now  become  better 
known.  And  so  long  as  there  exists  a  class  of  indivi- 
duals whose  deviation  from  the  normal  state  can  be 
expressed  in  no  clearer  terms  than  that  they  are  "  deli- 


INTRODUCTORY.  1 3 

cate  "  and  "  of  feeble  constitution,"  so  long  must  medical 
knowledge  be  considered  incomplete.  Scrofula  has  been 
bounded  extensively  by  this  chaotic  district,  and  from 
time  immemorial  there  has  been  a  reciprocity  between 
them.  It  is  no  wonder  then  if  the  limits  of  the  disease 
have  been  ever  confused  and  fluctuating.  In  less  modern 
times  any  chronic  state  of  ill-health  was  accredited  to 
scrofula,  and  even  now  this  tendency  is  not  quite- 
extinguished.  As  Henle*  well  remarks,  "  Scrofula  is  the 
receptacle  into  which  one  vaguely  casts  all  the  ailment:, 
which  afflict  children  under  fourteen  years,  and  of  which 
we  do  not  know  the  cause."  Before  hereditary  syphilis 
was  understood  all  its  manifestations  were  classed  as 
scrofulous  ;  rickets  also  was  a  strumous  disease,  as  was 
also  chronic  hydrocephalus.  Lugol,f  still  more  gene- 
rous, mentions  favus,  lice,  and  worms  as  scrofulus  dis- 
orders. Carmichael  ^  discovered  that. scrofula  and  dia- 
betes were  allied  ;  while  Hamilton  §  observes,  "  I  never 
knew  a  scirrhus  or  a  cancer  take  place  but  in  a  scrofu- 
lous habit." 

2.  The  second  cause  for  the  unstable  position  of 
scrofula  in  general  pathology  depends  upon  an  ancient 
impression  that  every  disease  or  diathesis  must  have 
some  specific  anatomical  feature  associated  with  it.  The 
outcome  of  this  impression  has  brought  into  the  field 
the  subject  of  tuberculosis.  Since  tubercle  was  first 
described  its  fortunes  and  those  of  scrofula  have  been 
linked  together.  In  all  its  changes,  in  all  its  losses,  in 
all  the  false  positions  into  which  it  has  been  thrust  first 
by  one  pathologist  and  then  by  another  scrofula  has  had 
a  share.  Scrofula  at  one  time  posed  as  a  tubercular 
process,  tubercle  at  another  has  been  described  as  a 
scrofulous  process.  Once  more,  the  two  conditions 
have  been  quite  distinct  and  have  even  been  antagon- 
istic ;  and  lastly,  they  have  been  identical  and  with  no 

*  '*  Handbuch  der  rationellen  Pathologie,"  1846-53. 

f  ' '  Researches  and  Observations  on  the  Causes  of  Scrofulous  Diseases." 
Translated  by  W.  H.  Ranking.     London,  1844. 

\  "On  the  Nature  of  Scrofula,"  by  Richard  Carmichael.  London, 
1810,  p.  21. 

§'•  Observations'on  Scrofulous  Affections,"  by  R.  Hamilton,  M.  D. 
London,  1791,  p."  65. 


14  SCROFULA  AND  TUBERCLE. 

line  of  separation  between  them.  The  very  term 
"  tubercle  "  has  experienced  a  violent  series  of  fluctua- 
tions. It  has  been  applied  first  to  one  appearance  and 
then  to  another  ;  its  limits  have  been  terribly  curtailed  ; 
vaunted  specific  features  have  one  by  one  been  removed 
from  it,  until  it  must  be  owned  that  the  tubercle  of  to- 
day is  but  a  poor  and  bald  affair  as  compared  with  the 
tubercle  of  the  time  of  Laennec. 

The  forced  association  of  scrofula,  therefore,  with  this 
vague  pathological  element,  the  very  Proteus  of  patho- 
logy, can  in  some  way  account  for  the  uncertain  position 
the  disease  has  occupied  from  time  to  time,  and  for  the 
somewhat  indefinite  outlines  it  still  retains.  At  the  same 
time  it  must  be  owned  that  much  good  has  been  done  by 
the  extensive  investigations  that  have  been  pursued  on 
the  subject  of  tubercle,  although  the,y  have  tended  a  little 
too  much  towards  an  attempt  to  demonstrate  a  specific 
element  for  a  certain  class  of  disease.  Thus  it  happens 
that  few  additions  to  our  knowledge  of  the  histology  of 
so-called  tubercular  affections  have  been  made  that  have 
not  been  seriously  burdened  by  theoretical  matter.  New 
facts  have  been  immediately  hampered  with  some  new 
theory  or  some  old  dogma,  and  the  results  of  pure  inves- 
tigation have  often  been  lessened  in  value  by  speculation 
and  conjecture.  These  difficulties,  clinical  and  patholo- 
gical, while  they  can  perhaps  explain  the  vagueness  that 
still  marks  the  scrofulous  process,  may  indicate  the 
direction  it  would  be  well  to  pursue  in  any  subsequent 
inquiries. 


CHAPTER  II. 

SCROFULA  AND   TUBERCLE. 

Inasmuch  as  scrofula  is  so  closely  bound  up  with  the 
subject  of  tuberculosis,  the  first  point  to  be  considered 
in  discussing  the  pathology  of  the  former  disease  is  the 
nature  of  tubercle  and  its  relations  to  the  scrofulous 


SCROFULA   AND   TUBERCLE.  I 5 

process.  It  is  obvious  that  no  definition  of  scrofula  can 
be  attempted  until  this  relationship  has  been  clearly  set 
forth. 

The  term  "  tubercle  "  was  originally  applied  to  a  cer- 
tain nakecj  eye  appearance,  to  little  distinct  specks  or 
spots  of  diseased  tissue  that  were  conspicuous  as  nodules 
or  tubercles.  When  first  used  the  term  "  tubercles " 
had  no  more  clinical  significance  than  has  the  term 
"nodular;"  and  it  is  remarkable  to  note  how  in  time  a 
clinical  meaning  of  the  most  emphatic  character  attached 
itself  to  the  term,  and  has  since  clung  to  it.  So  close 
is  this  connection  that  it  is  almost  impossible  to  sepa- 
rate certain  anatomical  appearances  from  certain  clinical 
conditions ;  and  no  matter  to  what  structural  change 
the  word  tubercle  is,  or  has  been,  applied,  there  still 
lurks  behind  it  a  subtle  suggestion  of  a  distinct  clinical 
state,  known  as  the  tubercular  condition.  The  term 
was  for  a  time  applied  to  many  states  of  tissue,  that 
although  anatomically  different,  yet  possessed  the  com- 
mon feature  of  being  nodular  in  outline.  A  better 
restriction  of  the  word  was  arrived  at  when  it  was  set 
forth  that  some  of  these  nodules  were  grey  and  clear, 
while  others  were  yellow  and  opaque.  Thus  arose  a 
division  of  tubercle  into  the  grey  and  the  yellow 
varieties.  The  yellow,  or  so-called  crude,  tubercles  were 
for  the  most  part  caseous  masses,  or  at  least  masses 
advanced  in  that  decay  ;  and  they  had  soon  to  be  elimi- 
nated from  the  domain  of  tubercle  when  it  was  shown 
that  caseation  was  by  no  means  limited  to  what  was 
known  as  the  tubercular  process.  With  regard  to  the 
other  tubercles,  the  grey  variety,  it  was  found  that 
such  nodules  when  met  with  in  the  lung  were  often  made 
up  solely  of  little  masses  of  alveolar  epithelium,  the 
results  of  a  lobular  catarrh.  All  such  nodules,  therefore, 
had  to  be  eliminated,  and  still  finer  distinctions  laid 
down  as  characteristic  of  tubercle.  The  term  was  then 
restricted  to  such  grey  semi-transparent  bodies  as  were 
not  merely  masses  of  catarrhal  exudation,  and  that, 
while  retaining  the  size  of  a  millet  seed,  were  hard  and 
firm.  These  tubercles,  it  was  noted,  in  time  became 
opaque  in  the  centre  and  then  wholly  caseous,  and  had 


l6  SCROFULA   AND   TUBERCLE. 

a  tendency  to  fuse  together  and  form  larger  masses. 
The  name  of  miliary  tubercle  was  given  to  them,  and  in 
the  disease  known  as  acute  miliary  tuberculosis  they 
were  considered  to  be  met  with  in  perfection.  In  time, 
however,  certain  tissue  changes  were  noted,  which  were 
regarded  as  tubercular,  but  which  were  not  associated 
with  the  appearance  of  these  distinct  grey  masses.  In 
the  place  of  such  masses  certain  microscopic  nodules 
alone  were  detected  that  were  found  to  possess  a  fairly 
simple  structure  ;  and  as  it  was  observed  that  certain  of 
the  grey  miliary  tubercles,  visible  to  the  naked  eye, 
were  simply  made  up  of  a  collection  of  these  micro- 
scopic nodules,  the  latter  were  distinguished  by  the 
term  submiliary  tubercle.  It  must  be  owned  that  for  a 
long  while  the  microscopic  features  of  tubercle  were 
very  indefinite  and  confused,  and  it  was  not  until  this 
finer  restriction  of  the  word  was  adopted  that  anything 
like  uniformity  was  obtaintd  in  histological  descriptions. 
These  little  microscopic  nodules  were  found  to  be  of 
common  occurrence,  and  capable  of  undergoing  the 
final  degenerative  process,  without  having  first  formed 
themselves  into  the  larger  masses  known  as  miliary 
tubercles.  It  is  to  these  microscopic  nodules  only  that 
the  bare  term  "tubercle"  is,  in  its  strictest  sense,  now 
applied.  Thus  it  will  be  seen  that  the  anatomical 
ground  on  which  tubercle  rests  has  been  from  time  to 
time  curtailed,  and  that  the  large  basis  it  originally 
possessed  has  been  cut  down  at  last  to  a  very  minute 
point.  This  submiliary  mass,  this  ultimate  tubercle  has 
been  described  by  many  observers,  and  has  received 
many  names ;  but  although  the  terms  used  differ,  and 
although  some  descriptions  are  a  trifle  modified  from 
the  rest,  yet  there  is  so  much  general  accord  that  patho- 
logists of  the  present  day  appear  to  be  at  least  agreed 
as  to  what  tubercle  looks  like,  even  if  they  disagree  as 
to  what  it  is.  It  must  be  understood  that  tubercle  in 
its  simplest  sense  refers  to  the  most  typical  stage  of  a 
certain  tissue  change,  and  that  to  the  process  that  pre- 
ceeds  its  appearance,  as  well  as  to  that  that  follows,  the 
term  tubercular  can  be  applied. 

Histology    of    Tubercle.  —  This    simple    submiliary 


SCROFULA   AND   TUBERCLE.  1 7 

tubercle  has  been  described  under  many  names,  as 
"  primitive  or  elementary  tubercle"  by  Koster,  as  "tuber- 
cular follicle"  by  Charcot,  as  "reticular  tubercle"  by  E. 
Wagner.  All  these  terms  may  be  regarded  as  synony- 
mous.    The  structure  of  such  a  tubercle  is  this : 

It  is  composed  of  a  mass  having  a  fairly  rounded  out- 
line, and  made  up  principally  of  cells.  These  cells  are  so 
arranged  as  to  form  in  typical  specimens  three  zones. 
The  central  part  is  occupied  by  one  or  more  giant  cells, 
round  this  is  a  zone  of  many  so-called  epithelioid  cells, 
and  beyond  this  is  a  third  zone  of  simple  embryonic 
cells  or  leucocytes.  All  these  cell  elements  are  sup- 
ported by  a  fine  reticulum,  which  is  generally  concen- 
trically arranged  at  the  periphery,  and  towards  the 
centre  is  observed  to  be  continuous  with  the  processes 
that  commonly  come  off  from  the  giant  cells.  The 
affected  district  is  non-vascular.  Such  is  a  typical 
tubercle.  Modifications  of  structure  are,  however,  per- 
mitted. The  giant  cell  may  occupy  the  periphery,  or 
may  be  entirely  absent,  in  which  case  the  appearance 
is  supposed  to  be  maintained  by  the  character  of  the 
cells  in  the  mass,  their  obvious  changes,  and  their  gen- 
eral arrangement.  The  giant  cell,  although  not  specific 
of  tubercle,  is  usually  present,  and  if  any  differentia- 
tion is  adopted  with  regard  to  terms,  the  term  "follicular 
or  reticular  tubercle "  would  apply  to  the  perfectly 
developed  mass,  the  terms  "  elementary  or  primitive 
tubercle  "  to  those  nodues  that  show  less  perfect  evolu- 
tion, and  possess  perhaps  no  giant  cell.*  As  to  the 
structural  origin  of  tubercle  it  will  be  easily  understood 
that  great  diversity  of  opinion  exists.  Some  hold  that 
it  is  developed  from  connective  tissue,  and  is  a  connec- 
tive tissue  growth  ;f  others,  that  it  is  essentially  a  lym- 
phoid or  adenoid  structure.;};  Some  observers — and 
among  them  Cornil   and    Ranvier§ — refer  its  origin  to 

*  For  a  brief  but  excellent  account  of  the  grades  of  tubercle,  see  Art. 
by  Dr.  Grancher  in  "L'Union  Medicale,"  vol.'  xxxi    18S1,  p.  873. 

f  See  exposition  of  this  view,  by  Dr.  D.  J.  Hamilton.    "  Practitioner," 
August  188 1. 

%  "On   the  Artificial  Production   of  Tubercle,"   by  Dr.  Wilson  Fox. 
London,  1868,  p.  25, 

§  "  Manuel  d'Histologie  pathologique.     Paris  1881,  vol.  i.  p.  236. 
2 


1 8  SCROFULA  AND  TUBERCLE. 

the  vessels  of  the  part,  and  state  that  a  coagulum  forms 
in  the  blood  capillary,  the  endothelium  of  whose  wall 
vigorously  proliferates,  so  that  on  section  the  coagulum 
is  seen  to  form  the  mass  of  a  giant  cell,  and  the  prolif- 
erated endothelium  its  many  nuclei.  If  the  vessels  be 
larger  changes  take  place  in  its  walls,  and  the  various 
zones  of  the  tubercle  are  then  considered  to  correspond 
to  the  various  tunics  of  the  artery.*  Others,  again, 
regard  the  giant  cell  as  a  protoplasmic  mass,  and  con- 
sider that  it  indicates  a  return  of  the  tissue  to  a  more 
embryonic  state.f  Those  who  hold  this  view -believe 
that  all  gradations  can  be  observed  between  the  epithe- 
lioid cells  and  the  leucocytes  on  the  one  hand,  and  the 
giant  cells  on  the  other.  Lastly,  among  other  views 
may  be  noted  one  that  applies  only  to  the  lung,  and  is 
to  the  effect  that  these  giant  cells  are  formed  by  the 
fusion  of  the  epithelial  cells  of  the  lung  alveoli.;}:  These 
— although  but  a  few  of  the  theories  that  have  been 
advanced — are  perhaps  the  most  representative,  and 
will  be  more  fully  discussed  in  the  chapter  on  the 
Pathology  of  Scrofulous  Glands. 

Such  being  tubercle,  the  first  question  to  be  asked  is 
this — Does  this  tubercle  present  any  specific  anatomical 
element  ?  It  assuredly  does  not.  Lebert§  some  years 
ago  endeavored  to  establish  the  specific  character  of  cer- 
tain cells  in  tubercle,  the  so-called  "  tubercle  corpuscles," 
but  his  conclusions  were  soon  found  to  be  erroneous  ; 
and  indeed  these  "  corpuscles"  were  none  other  than 
shrivelled  cells,  not  distinguishable  from  shrivelled  pus 
corpuscles.  Schuppel,|  again,  in  more  recent  times 
endeavored  to  maintain  the  specific  character  of  the 
giant  cell,  and  urged  that  this  structure  was  peculiar  to 
tubercle,  and   indeed  diagnostic  of  it.     This  argument 

*  M.  Kiener.  "Discussion  before  La  Societe  Medicale  des  hopi- 
taux.     L'Union  Medicale,"  vol.  xxxi.  1881,  p.  316. 

f  See  on  this  point  "  Epeer.  Untersuch.  uber  die  Herkunft  der  Tuber- 
kelelemente,"  etc.     Wurburg,  1875,  by  E.  Ziegler. 

X  Dr.  E.  Klein.  "  The  Anatomy  of  the  Lymphatic  System — The 
Lung."     London,  1875,  p.  76. 

8  "  Physiologie  Pathologique.     Paris,  1845. 

If  Dr.  Oskar  Schuppel.  '' Untersuchungen  uber  Lymphdrusen  Tuber- 
kuiose.     Tubingen,  1871. 


SCROFULA  AND  TUBERCLE.  19 

has,  however,  been  overthrown,  and  it  is  now  known 
that  giant  cells  are  to  be  met  with  under  the  most 
varied  circumstances  and  in  conditions  that  could  in  no 
way  be  termed  tubercular.  Thus  they  have  been  found 
in  simple  chronically  inflamed  connective  tissue,  in 
chronic  ulcers,  in  gummata,  in  erosions  of  the  os  uteri,* 
and  in  many  other  parts  and  tissues.  Although  giant 
cells  cannot  be  regarded  as  special  to  tubercle,  yet  it 
must  be  owned  that  they  are  not  commonly  met  with 
unassociated  with  that  product.  The  anatomical  indi- 
viduality of  tubercle  therefore  depends  upon  no  especiai 
factor  or  element,  but  must  rest  upon  the  general  con- 
formation of  the  mass,  the  grouping  of  its  parts,  the 
relation  it  holds  to  the  tissues  around,  and  above  all  to 
its  history,  its  tendencies,  its  peculiar  progress.  The 
most  remarkable  features  of  the  nodule  are  perhaps  its 
early  non-vascularity,  its  tendency  to  caseation,  its  apti- 
tude for  spreading  locally  and,  under  certain  conditions, 
generally,  and  its  action  when  inoculated  experimentally 
in  animals.  Other  points  in  the  history  of  tubercle  will 
be  considered  subsequently. 

Scrofula  and  Tubercle. — The  ground  is  now  prepared 
for  a  discussion  of  the  relations  between  scrofula  and 
tubercle.  As  a  preliminary  step  some  definite  meaning 
must,  for  the  purpose  of  this  discussion,  be  attached  to 
the  terms  "  scrofulous  "  and  "  tuberculous."  It  is  obvious 
that  at  the  present  stage  of  the  enquiry  those  terms 
cannot  be  used  in  an  anatomical  sense,  and  must  there- 
fore be  applied  temporarily  to  certain  clinical  conditions. 
For  the  present  purpose  then  the  terms  "  tuberculosis  " 
and  "  tuberculous "  will  be  considered  as  applying  to 
such  diseases  as  acute  miliary  tuberculosis,  tubercular 
peritonitis,  tubercular  meningitis,  and  the  term  "  scrofu- 
lous "  to  those  diseases  commonly  known  by  that  name, 
as,  for  example,  glandular  enlargements,  certain  chronic 
bone  and  joint  affections,  cold  abscess,  certain  ulcers 
and  eruptions  of  the  skin  and  mucuous  membranes. 

It  would  be  well  to  omit  phthisis  from  either  cate- 


*  Dr.  Carl  Friedlander.     "  Ueber  locale  Tuberculose."     Volkmann's 
"Sammung,"  No.  64,  1873. 


20  SCROFULA  AND  TUBERCLE. 

gory,  as  it  will  be  separately  discussed  by-and  bye.  Is 
tubercle- — as  just  described — met  with  in  scrofulous 
affections  ?  To  this  question  an  affirmative  answer  must 
most  certainly  be  given.  In  scrofulous  lymphatic  glands 
the  most  perfect  and  most  typical  tubercle  is  to  be  met 
with;  in  the  synovial  membrane,  and  in  the  bone' in 
cases  of  so-called  strumous  joint  disease  perfect  tubercle 
has  been  discovered.  Dr.  Lannelongue  has  lately  shown 
the  origin  of  cold  abscess  from  tubercular  deposit,  and 
demonstrated  the  progress  of  such  abscesses  by  exten- 
sion of  the  so-called  tuberculous  process.  Tubercle  also 
is  to  be  found  in  the  floor  of  scrofulous  ulcers,  in  lupus, 
in  certain  affections  of  the  mucous  membrane,  and  in 
other  parts.  If  this  be  the  case  there  would  appear  to 
be  no  difficulty  in  establishing  the  fact  that  scrofula  is 
what  is  termed  anatomically  a  tubercular  process.  But 
this  proposition  is  not  so  simple  as  it  seems,  and  much  of 
the  difficulty  that  surrounds  it  is  due  to  the  severe  and  def- 
inite clinical  meaning  that  attaches  to  the  term  proposed. 
In  the  first  place,  these  tubercles  are  not  met  with  in 
all  scrofulous  affections.  In  the  superficial  skin  erup- 
tions, in  some  of  the  more  common  affections  of  the 
mucous  membranes,  and  in  many  typically  scrofulous 
glands,  no  tubercle  is  to  be  met  with.  And,  again,  the 
presence  of  tubercle  has  not  been  demonstrated  in  all 
cases  of  disease  of  bone  and  joint  observed  in  the 
scrofulous.  Thus  it  happens  that  some  pathologists 
would  limit  the  term  "  scrofulous  "  to  those  affections 
only  that  present  no  tubercle,'  and  reserve  for  the  rest 
the  term  "tuberculous."  It  is  chiefly  with  regard  to 
the  lymphatic  glands  that  this  division  of  disease  has 
been  urged,  and  by  no  one  more  vigorously  than  by 
Cornil.*  But  it  must  be  remembered  that  there  are 
grades  and  degrees  in  the  tubercular  process,  just  as 
there  are  varieties  and  degrees  of  inflammatory  action. 
In  some  cases  the  tubercular  action — if  I  may  be 
allowed  the  term — does  not  proceed  so  far  as  the 
formation  of  tubercle,  just  as  all  inflammations  do  not 


*  Jotirnal  de  V anatomie  ~et  de  la pkysiohgie  (Charles  Robin).     Paris, 
1878,  No.  3. 


SCROFULA  AND  TUBERCLE.  21 

always  proceed  to  the  formation  of  pus.  At  any  point 
in  the  tubercle-producing  process  the  action  may  end 
and  caseation  set  in. 

Many  scrofulous  glands  caseate  without  developing 
any  tubercle,  but  in  the  process  that  precedes  such 
caseation  one  recognizes  a  state  that  is  at  least  prelimi- 
nary to  the  formation  of  the  nodule,  a  pre-tubercular 
state  as  it  may  be  termed.  Tubercle  is  the  most 
finished  structural  change  of  a  certain  process,  and  such 
dipfriodc  d'ttat  may  never  be  reached  in  a  vast  number 
of  strumous  disorders.  Now  it  appears  unreasonable 
to  make  a  conspicuous  division  between  these  two 
grades  of  gland  affection — the  gland  that  shows  tubercle 
and  the  gland  that  just  falls  short  of  that  product. 
They  are  both  essentially  tubercular,  and  terms  should 
not  be  applied  to  their  morbid  conditions  that  would 
indicate  more  than  differences  in  degree.  But  those 
who  assert  the  distinction  of  scrofula  from  tuberculosis 
term  those  glands  that  show  perfect  tubercle  tuber- 
culous, and  those  that  present  only  the  immature  struc- 
ture scrofulous.  This  use  of  terms  would  not  be  objection- 
able had  it  only  an  anatomical  basis,  and  did  not  a  very 
rigorous  clinical  meaning  associate  itself  with  these 
two  adjectives.  Cornil,  and  those  who  follow  his  teach- 
ing, do  not  limit  themselves  to  structural  differences, 
but  lay  down  clear  clinical  distinctions  between  the 
scrofulous  and  the  tubercular  gland.  As  regards  at 
least  the  external  glands — and  it  is  with  these  that  we 
are  now  most  concerned — I  must  assert  that  these 
clinical  distinctions  are  not  clearly  marked  and  can 
hardly  be  maintained.  I  own  that  there  are  affections 
of  internal  glands  (those  of  the  mesentery,  for  example) 
that  present  perfect  tubercle,  and  yet  follow  a  course 
so  distinctive  and  often  so  detrimental  that  they  are 
clinically  removed  from  the  category  of  what  is  com- 
monly known  as  scrofula.  Such  glands,  however,  differ 
from  the  simply  scrofulous — to  use  that  term  in  its 
usual  sense — only  in  degree,  and  the  evils  that  attend 
their  development  depends  mainly  upon  the  cause  and 
locality  of  the  disease. 

It  will  be  said  that  all  this  is  merely  a  matter  of 


22  SCROFULA  AND  TUBERCLE. 

terms,  It  is  so ;  but  certain  circumstances  conspire  to 
make  it  also  a  matter  of  importance.  The  term  "  tuber- 
cular" is  used  in  a  double  sense.  It  is  applied  to  an 
anatomical  condition — to  any  disease  presenting  per- 
fect tubercle — and  it  is  also  applied  to  certain  clinical 
states.  Unfortunately  these  two  conditions  do  not 
quite  coincide  and  the  presence  of  tubercle  does  not, 
of  necessity,  imply  that  grave  state  of  health  associated 
with  the  word  "  tuberculosis."  Tubercle  has  to  a  great 
degree  been  discussed  in  connection  with  acute  miliary 
tuberculosis  and  certain  lethal  lung  affectioms  ;  and 
from  ancient  custom  or  ancient  bias  it  has  somehow 
become  associated  with  all  the  grave  clinical  import  of 
these  diseases.  This  is  much  to  be  regretted,  and  con- 
stitutes a  bias  of  evil  consequence.  In  a  little  patch  of 
lupus  on  the  face  perfect  tubercle  may  be  found.  Is  a 
patient  so  affected  to  be  called  tuberculous  in  the  usual 
clinical  sense  ?  Is  he  likely  to  die  of  some  acute  and 
sudden  tubercular  mischief?  Is  he  not,  on  the  con- 
trary, as  likely  to  attain  old  age  as  is  the  majority  of 
other  persons  ?  One  can  quite  understand  from  a  case 
such  as  this  the  vigor  with  which  the  application  of  the 
term  tuberculous  to  such  a  disease  would  be  combated. 
Perfect  tubercle  is  met  with  in  lymphatic  glands,  but 
such  glands  after  a  time  may  eliminate  the  disease  and 
a  cure  result  followed  by  no  bad  consequence.  Leav- 
ing even  scrofulous  affections,  one  finds  tubercle  in 
other  diseases  quite  remote  from  any  clinical  associa- 
tion with  tuberculosis.  Koster  has  described  miliary 
tubercle  in  osteo-myelitis,  in  chronic  pericarditis,  in  the 
primary  syphilitic  sore,  in  elephantiasis  of  the  labia, 
and  in  other  conditions.  To  apply  the  clinical  term 
"  tuberculous  "  to  such  cases  would  simply  be  ridicul- 
ous. This  injurious  use  of  the  term  proceeds,  I 
imagine,  to  a  great  degree  from  the  general  attempt  to 
associate  every  diathesis  and  disease  with  some  specific 
anatomical  element.  The  logic  has  been  as  follows : 
Tubercles  are  found  in  acute  miliary  tuberculosis  and 
other  fatal  diseases  ;  these  diseases  are  called  tubercul- 
ous, therefore  every  other  disease  that  presents  tubercle 
must  also  be  tuberculous. 


SCROFULA  AND  TUBERCLE.  23 

As  M.  Ferrand  *  well  observes,  "  tubercle  does  not 
constitute  a  disease  any  more  than  does  suppuration." 
It  is  the  exclusive  indication  of  no  one  malady  and  the 
outcome  of  no  one  special  state  of  defective  health. 
Although  one  recognizes  the  fact  that  tubercle  appears 
in  scrofula,  yet  one  is  positively  loth  to  term  scrofula  a 
tuberculous  disease  ;  and  I  would  almost  go  so  far  as  to 
say  that  it  would  be  well  not  to  call  it  a  tuberculous 
disease,  until  the  bias  associated  with  the  latter  term 
has  been  removed,  until  that  term  is  accepted  in  a 
more  generous  and  rational  sense,  and  until  it  ceases  to 
attempt  to  force  an  alliance  between  an  anatomical 
appearance  and  a  clinical  state. 

To  return  to  the  relationship  between  scrofula  and 
those  affections  that  may  still  for  distinction  be  termed 
tuberculous.  Dr.  Grancher  f  urges  that  in  scrofula  an 
immature  or  embryonic  tubercle  is  alone  met  with,  and 
that  the  adult  or  completely  developed  tubercle  does 
not  usually  occur  in  the  disease,  but,  on  the  contrary, 
is  the  main  attribute  of  tuberculosis  exclusively  so 
called.  He  regards  scrofula  therefore  as  "  une  tuber- 
culose  attenu^e,"  as  a  milder,  less  perfect,  less  developed 
form  of  tuberculosis.  He  owns  the  perfect  identity  of 
the  two  affections,  and  insists  that  they  differ  only  in 
degree,  in  age,  in  the  matter  of  maturity.  In  this 
sense,  therefore,  he  speaks  of  scrofula  also  as  "  une 
tuberculose  naissante,"  "  une  tuberculose  au  premier 
degre."  Here,  however,  it  must  be  stated  that  the 
immature  tubercle  of  Grancher  corresponds  fairly  to 
the  tubercle  already  described  as  the  elementary  or 
primitive  tubercle,  or  tubercular  follicle ;  while  the 
adult  tubercle  of  which  Grancher  speaks  is  represented 
by  the  grey  granulation  of  Laennec.  This  mass,  often 
visible  to  the  naked  eye,  is  well  known  as  the  simple 
miliary  tubercle.  It  «is  hard  and  firm,  has  a  tendency 
to  fibrous  transformation,  and  is  merely  a  conglomera- 
tion of  the  smaller  and  simpler  tubercle  masses  already 


*  Z' Union  Medicate,  vol.  xxxi.  1881,  p.  40. 

\  "  Dictionnaire     encyclopedique     des    Sciences     Medicales.     Art. 
Scrofule."     Paris,  1880  p.  304. 


24  SCROFULA  AND  TUBERCLE. 

described.  This  conglomeration  is  fairly  considered  to 
indicate  a  more  complete  development  of  the  process. 

It  is  certainly  true  that  this  large  adult  granulation 
is  very  rarely,  if  ever,  met  with  in  truly  scrofulous 
affections.  In  scrofula  the  tubercular  process  seldom 
attains  to  so  elaborate  a  structure,  but  ends  in  caseous 
degeneration  before  the  formation  of  such  a  mass  is 
reached.  Dr.  Grancher,  moreover,  takes  a  wide  view 
of  the  structure  of  this  embryonic  or  immature  tubercle 
found  in  scrofula.  He  asserts  that  although  it  often 
attains  to  that  perfection  of  structure  we  have  ascribed 
to  tubercle  it  might  still  be  represented  by  a  much  less 
definite  tissue.  It  may  appear  as  little  more  than  a 
cluster  of  embryonic  cells  recognizable  as  on  the  whole 
tubercular  by  its  arrangement,  its  progress,  its  general 
tendency,  and  termination,  as  well  as  by  its  surround- 
ings. Such  a  tissue  would  correspond  to  Virchow's 
"  granulation  tissue."  In  more  fully  developed  masses 
an  arrangement  of  cells  and  giant  cells  would  be 
observed  more  approaching  that  of  the  perfect  tubercle, 
and  would  fairly  accord  with  the  description  of  primi- 
tive tubercle  as  given  by  Koster.  To  this  "  immature 
tubercle  "  which,  I  must  repeat,  includes  not  only  the 
tubercle  as  we  have  defined  it,  but  also  those  less 
definite  masses  called  by  Virchow  "  granulation  tissue  " 
and  by  Cornil  "  ilots  strumeaux,"  he  proposes  to  give 
the  name  of  "scrofulome." 

Other  relations  between  scrofula  and  tubercle  have 
been  maintained.  Rindfleisch*  considers  scrofula  as  the 
starting-point  of  the  tubercle-producing  process.  He 
considers  that  the  tubercle  is  usually  derived  by  a  pro- 
cess of  infection  from  some  near  or  distant  seat  of  scro- 
fulous disease.  Thus  he  traces  the  connection  between 
certain  eruptions  of  tubercle  in  the  lung  and  a  prelimi- 
nary scrofulous  bronchitis.  Such,  being  the  connection 
existing  he  would  regard  scrofulous  patients  as 
extremely  liable  to  those  serious  clinical  conditions 
distinctly  termed  tuberculous.     He  states  that  tubercu- 


*"  Chronic  and  Acute   Tuberculosis.     Ziemssen's   Encyclopaedia     of 
Medicine"  vol.  v.  p.  638. 


SCROFULA  AND  TUBERCLE.  25 

losis  (in  a  clinical  as  well  as  anatomical  sense)  seldom 
oocurs  except  in  such  patients.  If  tubercle  appears  in 
a  gland  then  has  it  been  due  to  a  previous  scrofulous 
trouble,  to  a  scrofulous  catarrh  of  a  mucous  surface,  or 
some  similar  lesion.  Or,  to  take  another  example,  a 
tubercular  ulcer  may  commence  as  a  catarrh,  and  after 
a  time  tubercles  will  appear  at  its  base.  Here  he 
regards  the  preliminary  catarrh  as  scrofulous,  the  sub- 
sequent local  eruption  of  tubercles  as  tuberculosis. 
Such  a  distinction  as  this  is  cumbrous,  and  appears  like 
pedantic  elaboration.  It  is  evident,  moreover,  that 
Rindfleisch  limits  tubercle  by  clinical  lines,  and  restricts 
it  to  those  more  fatal  diseases  associated  with  the 
appearance  of  tubercle.  His  distinctions  indeed  appear 
to  be  almost  wholly  a  matter  of  terms,  since  he  does 
not  deny  the  very  close  and  indeed  direct  connection 
between  what  he,  however,  maintains  to  be  two  distinct 
morbid  states. 

Many  other  views  as  to  the  connection  between  scro- 
fula and  tuberculosis  depend  upon  the  results  of  experi- 
mental inoculation.  Some  pathologists,  for  example, 
regard  tuberculosis  as  an  infective  disease,  a  disease  not 
so  much  due  to  hereditary  diathesis  as  an  acquired 
malady  like  syphilis  or  glanders.  Relying  upon  the 
well-known  inoculation  experiments  they  urge  that  a 
true  diathesis  cannot  be  transmitted  by  inoculation, 
and  that  as  tuberculosis  may  arise  from  inoculation  it  is 
therefore  not  a  diathesis ;  whereas  the  products  of  scro- 
fula not  being  inoculable  that  malady  may  be  ranked 
with  the  diatheses.  As  to  the  relations  between  the 
two  they  would  urge  that  they  are  the  relations  of  soil 
to  seed.  Scrofula  is  the  soil,  tubercle  the  seed,  and  the 
point  of  contact  between  the  two  conditions  is  this — 
that  it  is  especially,  if  not  exclusively,  upon  the  soil  of 
scrofula  that  the  infective  tubercle  can  take  root  and 
develop.  M.  Rendu  f  has  vigorously  espoused  these 
views  in  a  recent  communication,  and  his  conclusions 
may  be  considered  as  representative  of  a  large  class  of 
theories.  The  introduction  into  the  question  of  an 
infective  character  for  tubercle  brings  us  to  discuss  : 

\Scrofule  et  Tuberculose.     L' Union  Medicale,  vol.  xxxi.  1881,  p.  53, 


26  SCROFULA  AND  TUBERCLE. 

The  Experimental  Inoculation  of  Tubercular  and  Scrofu- 
lous Products. 

These  experiments  have  been  very  elaborately  con- 
ducted by  Villemin,  Burdon  Sanderson,  Wilson  Fox, 
Klein,  and  others,  and  in  more  recent  times  by  Cohn- 
heim,  Hueter,  Schuller,  Klebs,  and  Deutschmann. 
The  earlier  experiments  consisted  in  inoculating  "  cer- 
tain animals"  with  tuberculous  matter.  The  material 
in  these  experiments  was  injected  into  the  pleural 
or  peritoneal  cavities,  or  introduced  under  the  skin. 
The  result  was  that  in  most  cases  the  animals  oper- 
ated upon  developed  a  disease  considered  as  akin 
to  acute  miliary  tuberculosis  in  man.  The  real  nature 
of  this  produced  disease  and  its  mode  of  develop- 
ment are  open  to  considerable  dispute,  but  as  in 
a  subsequent  chapter  I  propose  to  discuss  the  value 
of  these  experiments,  I  will,  in  this  place,  merely 
refer  to  them  as  means  of  diagnosing  between  scrofula 
and  tuberculosis.  It  was  argued  from  these  early 
experiments  that  tuberculosis  was  an  infective  disease, 
and  that  this  feature  distinguished  it  from  scrofula. 
But  then  the  result  of  certain  investigations — such  as 
those  by  Wilson  Fox — showed  that  when  this  tubercu- 
lar matter  was  introduced  under  the  skin  it  set  up  a 
kind"  of  local  scrofula,  a  suppurative  process  associated 
with  enlarged  and  subsequently  caseous  glands.  This 
then  at  once  appeared  to  show  that  the  relation  between 
scrofula  and  tuberculosis  was  very  close,  and  a  matter 
of  difference  in  degree  rather  than  in  kind.  The  only 
way  out  of  the  difficulty  was  to  call  the  local  manifes- 
tations tuberculous.  This  was,  of  course,  done.  But 
then  it  was  found  that  scrofulous  matters,  if  used  for 
these  experiments,  produced  the  so-called  general  tuber- 
culosis as  readily  as  tubercular  matter.  Indeed  the 
matter  from  a  caseous  gland  became  the  most  active 
and  favorite  agent  in  these  experiments.  Those  who 
still  clung  to  the  belief  that  tubercle  had  the  distin- 
guishing feature  of  being  inoculable  claimed  these 
cheesy  glands  as  tubercular,  and  so  the  field  of  scrofula 
was  narrowed  by  the  loss  of  its  most  typical  manifes- 


SCROFULA  AND  TUBERCLE.  27 

tation.  More  recent  experiments,  however,  now  show 
that  portions  of  the  fungous  granulations  from  "  white 
swellings"  of  joints,  the' pus  from  cold  abscess,  granu- 
lations from  so-called  scrofulous  osteitis  and  periostitis 
can  all  produce  general  tuberculosis  when  inoculated. 
Cohnheim,*  whose  experiments  are  most  elaborate  and 
extensive,  asserts  as  the  result  of  his  researches  that  all 
the  recognized  tubercular  and  scrofulous  processes, 
however  different  anatomically,  are  tubercular,  inas- 
much as  the  products  of  all  of  them  are  almost  equally 
active  on  inoculation.  So  far,  then,  the  identity  of  the 
two  affections  appears  to  be  confirmed  by  these  experi- 
ments ;  and  as  it  would  seem  that  products  from 
strictly  tuberculous  diseases  often  produce  readier 
results  than  those  from  strictly  scrofulous  diseases,  it 
may  be  further  argued  that  the  two  morbid  conditions 
differ  only  in  degree  as  has  been  elsewhere  maintained. 
But  even  now  some  pathologists  still  advance  the  opin- 
ion (which  I  give  in  the  words  of  M.  Villemin)  that 
"  tubercle  alone  gives  tubercle  by  inoculation."  Those 
who  retain  this  view  are  compelled  to  exclude  from 
scrofula  all  its  classical  features  ;  the  caseous  gland,  the 
cold  abscess,  osteitis,  periostitis,  and  "  white  swellings ;" 
and  all  that  they  can  leave  for  the  disease  are  a  few 
superficial  lesions,  the  products  of  which  will  in  time 
be  probably  found  to  be  inoculable,  and  then  for  M. 
Villemin  and  his  followers  scrofula  will  be  an  extinct 
disease.  It  is  needless  to  discuss  this  point  further. 
It  is  obvious  that  rigid  differences  between  scrofula  and 
tuberculosis  (to  keep  to  the  old  divisions)  cannot  be 
founded  upon  experiments.  The  discussion  becomes 
again  merely  a  matter  of  terms,  and  a  conflict  between 
clinical  and  anatomical  standpoints.  So  far,  however, 
as  these  experiments  affect  the  present  subject  they 
show: — 1.  That  tubercular  matter  when  introduced 
into  the  bodies  of  certain  animals  can  produce  at  first  a 
local  disease  not  distinguishable  from  scrofula.  In 
addition  to  the  results  already  mentioned,  M.  Kienerf 

*  "  Die  Tuberculose  vom  Standpunkt  der  Infectionslehre."     Leipsig, 
1880. 
f  L  Union  Medicate,  vol.  xxxi.  1881,  p.  316. 


28  SCROFULA  AND  TUBERCLE. 

has  shown  that  the  injection  of  tubercular  matter  into 
the  testis  can  induce  caseous  inflammation  of  that  body, 
and  into  the  knee-joint,  a  chronic  joint  disease  that 
fully  accords  with  the  common  notions  of  white  swell- 
ings. Cohnheim's  experiments  have  all  the  same  bear- 
ing, although  these  observers  may  refrain  from  applying 
the  term  scrofulous  to  the  results  produced.  2.  That 
scrofulous  matter  when  used  as  a  vehicle  for  inocula- 
tion can  produce  general  tuberculosis.  3.  That  tuber- 
cular matter  acts  often  more  vigorously  in  these  experi- 
ments than  does  strictly  scrofulous  matter.  From  these 
results  it  may  be  gathered  that  experimental  inocula- 
tion maintains  the  identity  of  scrofula  with  tuberculo- 
sis, and  at  the  most  can  only  show  that  the  two 
conditions  differ  somewhat  in  intensity  or  degree. 

I  must  again  point  out  that  throughout  this  discus- 
sion the  terms  "  scrofulous  "  and  "  tuberculous  "  or 
"  tuberculosis "  are  used  in  the  sense  detailed  at  the 
commencement  of  this  chapter,  and  refer  to  certain 
definite  clinical  diseases,  and  not  to  the  anatomical 
bases  of  any  disease. 

The  following  conclusions  may  be  stated  as  to  the 
relations  between  Scrofula  and  Tubercle. 

1.  The  manifestations  of  scrofula  are  commonly  asso- 
ciated with  the  appearance  of  tubercle ;  or  if  no  fully 
formed  tubercle  be  met  with,  a  condition  of  tissue 
obtains  that  is  recognized  as  being  preliminary  to  tuber- 
cle. Anatomically,  therefore,  scrofula  may  be  regarded 
as  a  tuberculous  or  tubercle-forming  process. 

2.  The  form  of  tubercle  met  with  in  scrofulous  dis- 
eases is  usually  of  an  elementary  and  often  of  an  imma- 
ture character.  Whereas  in  diseases  called  tuberculous 
in  a  strict  clinical  sense,  a  more  perfect  form  of  tuber- 
cle is  met  with  in  the  form  of  the  grey  granulation  or 
''adult  tubercle"  (Grancher). 

3.  Scrofula,  therefore,  indicates  a  milder  form  or  stage 
or  tuberculosis,  and  the  two  processes  are  simply  sep- 
arated from  one  another  by  degree. 


THF   NATURE   OF  TUBERCLE.  29 

CHAPTER    III. 

THE   NATURE   OF   TUBERCLE. 

As  scrofula  is  a  disease  associated  anatomically  with 
the  appearance  of  tubercle,  the  pathology  of  the  affec- 
tion naturally  rests  to  a  great  extent  upon  the  nature 
or  morbid  significance  of  this  remarkable  structure. 
As  may  be  supposed,  a  vast  number  of  theories  have 
been  advanced  in  connection  with  this  matter. 

To  discuss  even  the  most  prominent  of  them  would 
be  beyond  the  scope  of  this  book,  and  I  will  content 
myself,  therefore,  by  detailing  what  appears  to  me  to 
be  the  most  reasonable  explanation  of  the  nature  of 
tuberculosis.  I  believe  that  the  view  at  present  most 
generally  accepted  with  regard  to  tubercle  is  that  it  is  a 
neoplasm  or  new  growth ;  a  connective-tissue  growth 
according  to  some,  a  growth  from  adenoid  or  lymphoid 
tissue  according  to  others.  Whether  this  neoplasm  is 
of  embolic  origin  or  whether  it  is  developed  in  situ,  is 
of  no  concern  to  the  present  subject.  The  fact  remains 
that  in  spite  of  possible  differences  of  origin,  a  number 
of  pathologists  regard  tubercle  as  a  new  growth.  I, 
however,  would  venture  to  urge  that  tubercle  is  merely 
the  product  of  a  peculiar  form  of  inflammation  ;  that  it 
is  no  neoplasm  in  any  other  sense  than  that  it  is  an 
inflammatory  neoplasm.  The  inflammation  with  which 
it  is  associated  has  many  and  distinctive  features,  and 
these,  when  even  fairly  marked,  can  separate  it  from 
every  other  phase  of  inflammatory  action.  What  are 
these  peculiarities  need  not  here  be  discussed.  They 
will  be  fully  dealt  with  subsequently.  The  only  point 
to  establish  now  is  whether  the  mass  tubercle  is,  or  is 
not,  a  direct  product  of  inflammation.  On  this  point,  I 
will  draw  attention  to  these  facts.  The  appearance  of 
tubercle  is  frequently  preceded  by  an  inflammation  of 
undoubted  character  elsewhere,  which  stands  to  the 
nodule  in  the  relation  of  cause  to  effect.  As  a  con- 
spicuous instance  of  this,  I  might  cite  certain  gland 
enlargements.     An  enlarged  cervical  gland  can  often 


30  THE   NATURE   OF  TUBERCLE. 

be  definitely  traced  to  some  perfectly  simple  inflamma- 
tion, seated,  let  us  say,  within  the  mouth.  Now  one 
knows  the  well  marked  tendency  of  lymphatic  glands 
to  accurately  reproduce  morbid  conditions  transmitted 
to  them  from  the  periphery,  and  I  would  urge  that  the 
present  instance  forms  no  exception  to  that  rule.  The 
affected  gland  shows'  at  once  evidences  of  inflamma- 
tion, and,  in  fact,  faithfully  reproduces  the  process 
active  at  the  periphery.  But  in  time  the  simple  action 
assumes  more  peculiar  features :  the  products  of  the 
inflammatory  process  become  themselves  peculiar  ;  t'hey 
mass  themselves  together  in  a  strange  manner,  and  con- 
spicuous among  those  products  is  tubercle.  At  no 
time  in  the  course  of  the  gland  affection  could  one  say, 
here  inflammatory  action  ends  and  the  growth  of  a  neo- 
plasm begins.  In  no  case  of  gland  disease  that  I  have 
yet  met  with  has  the  process  commenced  by  the  deposit 
of  tubercle  in  a  tissue  that  is  absolutely  unchanged 
from  its  normal  condition  ;  and  although  at  least  one 
pathologist  *  speaks  of  such  an  occurrence,  I  must  ven- 
ture to  doubt  its  reality  until  it  is  supported  by  more 
detailed  evidence.  As  will  be  seen  in  the  chapter 
which  deals  with  the.  pathology  of  the  gland  affec- 
tions, the  appearance  of  tubercle  is  always  preceded 
by  changes  distinctly  inflammatory ;  changes  marked 
by  increased  vascularity  of  the  part,  extensive  exuda- 
tions and  active  cell  proliferation  ;  and,  although  as  the 
sequel  shows,  this  inflammation  assumes  distinctive  fea- 
tures, yet  its  general  nature  remains  unaltered.  Rind- 
fleischf  says  that  "it  is  often-  impossible,  in  a  given 
tubercular  lesion,  to  determine  how  much  is  inflamma- 
tory and  how  much  tubercular."  Dr.  Lannelongue,:}: 
who  is  a  firm  believer  in  the  entity  of  tubercle  as  a 
neoplasm,  is  yet  constrained  to  observe  in  dealing  with 
tuberculosis  of  bone,  that  the  osteitis  with  which  it  is 
associated  very  often  makes  its  appearance  before  the 


*"  Pathology  and  morbid  anatomy,"  by  Dr.   T.  H.   Green,  4th  ed. 
1878.     Fig.  70,  p.  241. 

\  "  Ziemssen's  Encyclopaedia,"  lac.  sit,  p.  647. 

\  "  Absces  Froids  et  Tuberculose  Osseuse."     Paris,  1881,  p.  133. 


THE   NATURE   OF   TUBERCLE.  31 

tubercle  is  met  with.  M.  Keiner,*  speaking  of  tuber- 
cles of  serous  membranes,  states  that  these  structures 
at  first  differ  in  no  way  from  the  products  of  simple 
inflammation.  Other  observers  maintain  the  same  fact, 
and  yet  when  the  products  become  peculiar,  inflamma- 
tion is  considered  as  withdrawn  from  the  field.  If  it  is 
allowed  that  the  process  is  at  its  outset  inflammatory, 
it  seems  most  illogical  to  assume  a  gross  and  sudden 
change  of  pathological  action,  simply  to  explain  appear- 
ances that  happen  to  differ  from  those  met  with  in  more 
familiar  inflammations.  Presuming,  on  the  other  hand, 
tubercle  to  be  a  neoplasm,  it  is  remarkable  that  through- 
out its  whole  course  it  should  be  so  very  frequently  and 
intimately  associated  with  inflammatory  change.  No 
other  neoplasm  shows  this  extraordinary  alliance.  I 
would  venture  to  say  that  no  new  growth  with  which 
pathology  has  rendered  us  familiar  makes  its  ddbut  so 
often  associated  with  inflammatory  change,  and  its  end- 
ing so  often  marked  by  suppuration  and  death  of  tissue, 
as  does  this  structure  tubercle.  It  may  be  that  the 
reputed  neoplasm  excites  inflammation  in  the  adjacent 
structures ;  but  if  that  be  allowed,  it  is  strange  that  it 
should  also  be  preceded  by  inflammation,  and  stranger 
still  that  a  peculiar  form  of  irritative  inflammation 
should  be  considered  by  many  as  needful  to  procure 
this  neoplasm.  Then,  again,  it  is  important  to  note 
the  elevation  of  temperature  that  is  associated  with  the 
appearance  of  tubercle,  and  that  would  point  also  to  its 
inflammatory  nature.  Dr.  Thaon,  who  supports  the 
theory  that  tuberculosis  is  due  to  a  special  inflamma- 
tion, remarks  that,  "  like  all  inflammations,  it  is  always 
accompanied  by  fever,  a  circumstance  not  observed  in 
cancer."  f 

Lannelongue  has  also  drawn  attention  to  the  local 
and  general  rise  of  temperature  noticed  in  cold  abscess, 
an  affection  that  he  has  shown  to  be  of  tubercular 
nature,  both  in  its  origin  and  also  in  its  subsequent 

*  "  De  la  Tuberculose  et'des  Affections  dites  scrof uleuses. "  JO  Union 
Medicate,  vol.  xxxi,  p.  316,  1881. 

f  "  Recherches  sur  la  Tuberculose  et  la  Scrofulose."  IJ  Union  Medi- 
cate, vol.  xxxi.  1 88 1,  p.  41. 


32  THE   NATURE   OF  TUBERCLE. 

progress.  M.  Du  Castel,*  a  supporter  of  the  theory  as 
to  the  inflammatory  nature  of  tubercle,  also  refers  to 
Peter's  observation  on  the  local  elevation  of  tempera- 
ture at  the  commencement  of  phthisis  as  pertinent  to 
the  present  subject. 

Then,  again,  the  curability  of  many  of  these  tuber- 
cular affections,  especially  those  that  are  more  properly 
included  in  scrofula,  would  appear  to  support  the  theory 
of  an  inflammatory  nature,  and  to  militate  against  the 
idea  of  a  neoplasm,  particularly  as  that  neoplasm  shows 
evidence  of  being  by  no  means  of  an  innocent  nature. 

A  neoplasm  that  can  multiply  as  fast  as  tubercle 
appears  sometimes  to  multiply,  that  can  spread 
with  so  marked  a  determination,  that  can  invade 
and  occupy  an  entire  organ,  must  be  regarded  as  a 
growth  from  which  a  spontaneous  cure  is  hardly  to 
be  expected.  Yet  perfect  tubercle  may  occupy  the 
the  length  and  breadth  of  a  gland,  and  yet  that  gland 
leisurely  caseates,  suppurates,  and  heals.  Moreover, 
the  tendency  sometimes  shown  by  tubercle  to  form  a 
fibrous  material  resembles  in  a  striking  manner  the 
tendency  commonly  exhibited  by  the  granulations  in  a 
simple  wound  to  develop  connective  tissue  ;  and  such 
a  transformation— although  it  may  be  only  occasional 
in  tubercle — does  not  accord  with  one's  notions  of  an 
active  new  growth.  Very  strong  support  has  been  given 
to  the  theory  of  the  inflammatory  nature  of  tubercle  by 
the  ingenious  experiments  of  Ziegler.f  Ziegler  induced 
inflammatory  changes  in  dogs  and  rabbits  by  inserting 
under  the  skin  or  in  some  of  the  cavities  of  the  body 
two  thin  discs  of  glass  so  cemented  together  that  fine 
interstices  were  left  between  them.  There  could  be 
nothing  specific  about  two  little  discs  of  glass,  and  the 
animals  experimented  upon  were  in  sound  health.  The 
discs  were  removed  at  varying  periods  and  examined. 
First  the  interstices  between  the  pieces  of  glass  were 
found  to  be  occupied  by  a  mass  of  leucocytes.     These 


*  L'  Union  Medicale,  vol.  xxxi,  i88r,  p.  138. 

f '  Experimen^'He  Untersuchungen  uber  die  Herkunft  der  Tuberkel- 
elemente,"  &c.   Wiirzburgs  1875. 


THE   NATURE   OF   TUBERCLE.  33 

often  underwent  degenerative  changes,  and  showed  no 
tendency  to  form  any  definite  structure.  In  other 
instances  vessels  were  observed,  giant  cells,  and  so- 
called  epitheloid  elements  made  their  appearance 
(developed,  Ziegler  presumes,  from  the  leucocytes),  a 
reticular  tissue  formed,  and  a  tubercle  was  the  result. 
Here  the  inflammatory  nature  of  tubercle  can  hardly 
be  called  in  question,  and  the  only  objection  that  in  this 
instance  can  be  raised  against  such  a  theory  lies  in  the 
bare  statement  that  in  the  class  of  animals  operated 
upon  there  is  a  tendency  for  the  growth  of  the  neoplasm 
tubercle  to  be  excited  by  slight  and  non-specific  irrita- 
tion. 

Birch-Hirschfeld,*  referring  to  these  experiments,  and 
arguing  also  upon  more  extended  bases,  asserts  that 
"  tubercle  might  be  regarded  as  a  degenerated  species 
of  inflammatory  neoplasm  (granulation)  determined  by 
necrobiotic  processes."  This  definition  affects  certain 
peculiarities  of  the  tubercular  process,  with  which  at 
this  moment  we  have  no  concern,  but  in  the  general 
principle  it  embodies  it  may  be  entirely  accepted. 

The  peculiar  form  of  the  inflammatory  process  that 
leads  to  the  appearance  of  tubercle  appears  to  have  no 
remote  parallel  in  the  inflammatory  changes  peculiar  to 
tertiary  syphilis.  A  trifling  wound  or  abrasion  inflicted 
upon  a  patient  suffering  from  tertiary  syphilis  often 
takes  on  a  very  remarkable  action.  A  similar  lesion  in 
a  healthy  individual  would  probably  heal  without  per- 
ceptible local  disturbance.  Owing  to  a  previous  blood 
disease  the  tertiary  syphilitic  is  liable  to  an  inflamma- 
tion of  a  perfectly  distinctive  type  ;  so  distinctive  that 
it  is  known  as  gummatous  and  its  specific  product  as  a 
gumma.  The  microscopic  appearances  of  a  gumma  do 
not  happen  to  be  of  so  remarkable  a  character  as  are 
those  incident  to  tubercle,  but  none  the  less  is  a  gumma 
a  distinct  and  marked  deviation  from  the  ordinary  type 
of  inflammatory  product.  No  one  would,  I  presume, 
assert  that  a  gumma  is  a  neoplasm  in  any  other  sense 

*Ziemssen's  "  Cyclopaedia  of  Practical  Medicine,  Art.  Scrofulosis,"  vol. 
xvi.  1877,  p.  758. 

3 


34  THE   INOCULABILITY   OF   TUBERCLE. 

than  that  it  is  an  inflammatory  neoplasm,  and  from  the 
standpoint  of  general  pathology  I  fail  to  see  why  a  like 
character  is  not  allowed  to  tubercle.  In  both  tubercu- 
losis and  in  tertiary  syphilis  there  is  a  tendency  to 
develop  inflammation  of  a  peculiar  type,  in  the  one 
instance  that  peculiarity  shows  itself  by  the  product 
tubercle,  in  the  other  by  the  product  gumma. 

I  will  make  no  mention  in  this  place  of  the  tubercles 
in  acute  miliary  tuberculosis.  That  disease  has  certain 
traits  that  are  peculiar  to  itself,  and  that  remove  it  from 
general  consideration.  To  introduce  the  subject  into 
the  present  question  would  be  akin  to  thrusting 
pyaemia  into  a  consideration  of  the  pathology  of  simple 
inflammation. 


CHAPTER   IV. 

THE  INOCULABILITY  OF  TUBERCLE. 

The  experiments  to  demonstrate  the  inoculability  of 
tubercle  have  been  very  extensive,  but  on  the  whole 
somewhat  meagre  of  good  results.  Caseous  matter 
from  a  tubercular  source  injected  into  the  pleural  cavity 
of  rabbits,  pigs,  and  other  animals,  induced  a  fatal  dis- 
ease associated  with  an  eruption  of  so-called  miliary 
tnbercles  in  the  lungs  and  other  parts.  This  disease 
was  considered  as  akin  to  acute  miliary  tuberculosis  in 
man.  From  experiments  of  this  character  tubercle  was 
considered  to  be  due  to  infection,  to  be  the  outcome  of 
some  occult  virus,  and  its  pathological  position  to  be 
among  infective  disorders.  There  is  no  doubt  that  these 
injections  of  caseous  matter  induce  a  fatal  disease  asso- 
ciated with  the  eruption  of  little  tubercular  nodules,  but 
the  objections  raised  to  the  conclusions  and  theories 
resulting  from  these  experiments  are  somewhat  obtru- 
sive. In  the  first  place,  is  the  disease  induced  in  these 
animals  acute  miliary  tuberculosis  ?  Many  urge  that  it 
is   not,   but  that  it  is  rather  of   the   nature  of   pysemic 


THE   INOCULABILITY   OF   TUBERCLE.  35 

infection.  Wagner  indeed  failed,  by  these  experiments 
to  develop  a  disease  that  he  could  regard  as  tubercular. 
It  appeared  to  him  rather  to  be  a  chronic  pyaemia.  Then, 
again,  the  majority  of  the  so-called  miliary  tubercles  were 
found  to  be  merely  masses  of  adenoid  tissue  developed 
from  the  lymphatic  structures  of  the  affected  part ;  and 
it  has  very  reasonably  been  urged  by  Friedlander  that 
as  these  masses  show  neither  epitheloid  cells  nor  giant 
cells  they  can  hardly  be  classed  as  true  tubercles.  In 
justice,  however,  to  those  who  maintain  the  tubercular 
nature  of  these  lesions,  it  must  be  stated  that 
in  the  lungs  of  animals  with  this  disease  undoubted 
tnbercular  masses  are  met  with,  although  they  may  not 
be  the  predominant  feature.  Certain  experiments  of 
Dr.  Wilson  Fox  appear  to  raise  a  more  serious  objection 
to  the  infection  theory.  He  found  that  the  injection  of 
caseous  matter  was  not  essential  for  the  production  of 
this  artificial  tuberculosis..  It  was  sufficient  in  certain  ani- 
mals ot  induce  suppurative  inflammation  by  means  of  a 
setou  simply  passed  beneath  the  skin  ;  this  inflammation 
became  caseous,  and  general  tuberculosis  followed. 
Like  experiments  by  others  have  verified  these  results, 
and  in  connection  with  such  may  be  mentioned  the 
injection  of  minute  non-animal  irritants.  Here,  then,  it 
would  appear  that  the  animal  had  the  power  of  manu- 
facturing the  infecting  material,  that  the  virus  could 
easily  be  generated  de  novo ;  and  it  must  be  owned  that 
this  supposition  somewhat  militated  against  those 
notions  of  infective  disease  that  are  derived  from  a 
study  of  syphilis  as  a  type  of  such  disorders.  But  in 
connection  with  this  point  it  was  asserted  that  certain 
animals  had  a  great  tendency  to  develop  caseous 
inflammation  from  trifling  causes,  and  as  it  was  known 
that  caseous  matter  is  not  the  only  means  of  conveying 
the  infection,  it  must  be  persumed  that  the  specific  virus 
was  developed  at  the  same  time. 

Buhl  *  asserted,  a  propos  of  the  same  matter,  that  in 
all  cases  of  general  tuberculosis  in  man,  a  previous  case- 

*  "  Lungen-Entzundung,  Tuberculosa und  Schroindsucht. "  Munchen, 
1872. 


36  THE   INOCULABILITY   OF  TUBERCLE. 

ous  mass  could  somewhere  be  found,  from  which  mass 
the  body  had  been,  as  it  were,  infected.  Rindfleisch,* 
going  a  step  further  in  the  same  direction,  is  inclined 
to  maintain  that  even  local  tuberculosis  proceeds  from 
some  previous  caseous  inflammation,  as  an  inficting 
focus.  Such  inflammations  he  considers  to  be 
scrofulous,  and  hence  the  close  connection  he  traces 
between  scrofula  and  tnberculosis  as  between  a  cause 
and  an  effect.  Quite  recently  Dr.  Creighton  f  has  given 
reasons  for  opposing  the  views  of  Buhl  and  others,  and 
concludes  that  disseminated  tuberculosis  does  not  origi- 
nate in  a  primary  source  of  infection  within  the  body, 
but  that  the  infecting  agent  is  a  virus  introduced  into 
the  body  from  without. 

The  whole  question  therefore  is  still  unsettled.  In 
all  the  experiments  above  alluded  to  it  was  noted  that 
local  changes  occurred  at  the  inoculated  spot,  that  these 
changes  extended  locally  within  certain  limits,  and  then 
became  general.  '  In  Dr.  Klein's  ^  experiments,  for 
exampfe,  where  matter  was  injected  into  the  pleural 
cavity,  a  chronic  pleuritis  was  the  first  result,  the  mor- 
bid changes  in  the  pleura  could  then  be  traced  by  direct 
continuity  of  tissue  into  the  lungs,  where  they  soon 
became  more  general.  In  like  manner,  in  the  researches 
of  others  it  was  shown  that  matter  injected  into  the 
peritoneal  cavity  §  first  induced  tuberculosis  of  the  peri- 
toneum, then  of  the  mesenteric  glands,  then  of  the 
pleura  and  mediastinal  glands,  and  lastly  of  the  lungs 
and  other  viscera.  So  with  regard  to  the  connective 
tissue  the  same  direct  continuity  of  diseased  action  was 
observed.  Caseous  inflammation  in  that  tissue  was  fol- 
lowed by  changes  in  the  corresponding  glands,  from 
whence  the  process  spread  more  generally.  M.  Kiener 
has  shown  that  if  the  matter  was  injected  into  the  knee 
or  the  testis,  local  tubercular  change  took  place  in  those 
parts  before  any  general  infection  occurred,  and  that 

* Loc.cit 

f  International  Medical  Congress,  1881.  "  Abstracts  of  Papers,"  sec. 
iii.  p.  39. 

%  "  Anatomy  of  the  Lymphatic  System, — The  Lung,"  1875  p.  tf.etseq. 
%  See  note  of  these  experiments,  by  M.  Kiener,  loc.  cit.,  p.  349. 


THE   INOCULABILITY   OF  TUBERCLE.  37 

when  such  infection  did  occur  a  structural  continuity  in 
the  morbid  processess  could  be  detected.  It  must  there- 
fore be  allowed  that  the  tubercular  process  when  once 
set  up  has  a  remarkable  tendency  to  spread,  and  that 
such  spreading  appears  to  be  mainly  promoted  by  the 
lymphatics;  that  it  is  a  process  that  infects  locally  must 
be  admitted,  but  that  it  constitutes  a  disease  peculiar 
in  so  far  that  it  can  be  transmitted  unmodified  from 
one  individual  to  another  would  appear  to  require  the 
support  of  some  further  facts.  It  must  be  freely 
acknowledged  that  in  certain  animals  the  inoculation  of 
tubercular  matter  produces  a  disease  having  an  eruption 
of  "  tubercles  "  as  its  principal  anatomical  features;  but 
to  maintain  the  theory  as  to  the  infective  nature  of 
tubercle  it  must  be  shown  that  no  other  matter  or  tis- 
sue can  produce  a  like  effect,  that  the  results  obtained 
are  independent  of  any  peculiar  morbid  tendencies  pos- 
sessed by  the  animals  experimented  upon,  and  that — 
while  a  reasonable  margin  is  allowed — the  result  of 
such  inoculations  are  constant.  Many  clinical  facts 
support  the  idea  that  tubercular  disease  may  be  trans- 
mitted from  one  individual  to  another.*  With  regard 
to  animals  this  transmission  has  been  chiefly  insisted 
on  in  cases  of  pearl  disease  (perlsucht)  in  cows,  it  being 
stated  that  pigs  when  fed  upon  the  milk  from  animals 
so  affected  become  in  many  instances  themselves  tuber- 
cular, f  Dr.  Creighton  ^  has  lately  urged  that  this 
disease  can  also  be  communicated  to  man,  the  vehicle 
being  the  milk  or  flesh  of  the  affected  animal.  With 
regard  to  man  also,  so  many  carefully  considered  cases 
have  been  recorded  a propos  of  the  communicability  of 
phthisis  that  it  is  hard  to  resist  the  conclusions  urged 
by  those  who  advance  them.     An  excellent  summary  of 

*See,  for  example,  a  case  by  Dr.  Guerin  (  "  Discussion  sur  la  Tuber- 
culose."  Bull,  del' Acad.  1867,)  where  a  man  with  tuberculosis  infected 
his  wife.  He  died.  She  mairied  again,  and  infected  her  second  hus- 
band. After  her  death  the  second  husband  marries  again,  and  com- 
municates the  disease  to  his  second  wife.  See  also  cases  by  Dr.  Villemin 
V  Union,  1868. 

f  See  Chauveau's  experiments  by  feeding  calves  with  tubercular  matter. 
"Gazette  de  Paris,"  p- 47,  1868. 

\  "  Baxine  Tuberculosis  in  Man."  London,  1881. 


38  THE   INOCULABILITY   OF  TUBERCLE. 

the  chief  points  that  have  been  advanced  to  support  the 
communicability  of  tubercular  affections  is  given  by 
Dr.  Klein  in  the  "  Practitioner''  for  August  1881.  He 
refers  to  a  large  number  of  illustrative  cases.  It  must 
be  confessed,  however,  that  the  "  virus  from  without  " 
theory  places  its  upholders  in  certain  awkward  positions 
when  they  proceed  to  discuss  the  clinical  bearings  of 
the  case  in  greater  detail.  Cohnheim,*  for  example, 
maintains  that  tuberculosis  of  the  air  passages  is  due  to 
a  tuberculosis  virus  that  has  been  inspired,  and  that  has 
been  inspired,  and  that  of  the  intestinal  canal  to  like 
matter  swallowed.  So  far  one  can  follow  him:  but  when 
he  attempts  to  explain  primary  tuberculosis  elsewhere 
it  must  be  confessed  that  his  explanations  are  at  the 
least  fanciful.  Thus  he  conceives  it  possible  that  in 
meningeal  tuberculosis  the  virus  may  enter  the  skull 
from  the  nose  via  the  cribriform  foramina ;  and  in  cases 
of  primary  tubercular  disease  of  the  kidney  it  is  needful 
to  assume  the  existence  of  a  virus  in  the  blood,  which 
virus  is  in  time  excreted  by  the  kidney,  and  so  becomes 
localized  in  the  gland.  In  the  same  way,  in  tuberculosis 
of  bone,  where  a  primary  injury  is  so  common,  he  sup- 
poses that  that  injury  attracts  a  virus  already  in  the 
blood  by  the  inflammation  it  excites.  It  must  be 
allowed  that  this  is  all  but  the  wildest  conjecture. 

Some  other  recent  experiments  as  to  the  inoculability 
of  tubercle  bring  out  fresh  aspects  of  this  vexed  ques- 
tion. These  experiments  I  will  briefly  allude  to.  Their 
real  significance  can  hardly  be  yet  discussed,  as  the 
whole  matter  is  still  snbjudice.  Klebs,  Hueter,  Schiil- 
ler,  and  others,-have  endeavored  to  show  that  the  tuber- 
cle virus  is  a  micro-organism,  and  that  can  be  best 
developed  for  inoculation  purposes  by  what  is  known 
as  "fractional  culture."  A  piece  of  tubercular  tissue  is 
treated  in  a  certain  manner,  and  in  the  fluid  about  it  a 
number  of  these  micro-organisms  {spaltpilze)  develop. 
If  the  fluid  that  contains  these  organisms  be  injected 
into  the  body  of  certain  animals  both  local  and  general 

*  ' '  Die   Tuberculose  vom  Standpunkt  der  Inf ectionslehre. "  Leipsig, 

1880. 


THE    INOCULABILTTY   OF   TUBERCLE.  39 

tuberculosis  is  produced,  although  the  injected  matter 
contained  actually  no  trace  of  the  original  piece  of  tis- 
sue employed.*  Deutschmann  f  has,  however,  more 
recently  repeated  these  experiments,  employing  a  some- 
what different  mode  of  procedure,  and  he  asserts  that 
with  a  fluid  containing  micrococci  identical  with  those 
described  by  Klebs  and  others,  he  obtained  only  nega- 
tive results,  and  in  no  case  succeeded  in  inducing  tuber- 
culosis. The  whole  question  therefore  must  be  con- 
sidered as  still  in  a  very  unsettled  condition. 

Schiiller's  experiments^:  show  also  that  certain  tuber- 
cular products  are  much  more  active  as  inoculating 
agents  after  cultivation  of  the  specific  micrococcus. 
Thus  lupus  tissue,  when  subjected  to  cultivation,  fur- 
nished a  fluid  that  on  inoculation  produced  both  local 
and  general  tuberculosis  ;  whereas  inoculation  with 
fresh  lupus  matter  either  led  to  no  results,  or,  as  in 
M.  Kiener's  cases,  to  but  a  slight  local  lesion.  Then, 
again,  in  another  series  of  experiments,  Schiiller  intro- 
duced tubercular  matter  into  the  trachea  of  an  animal 
without  inflicting  any  wound.  He  then  contused  one 
of  the  creature's  joints,  and  the  result  was  a  white 
swelling  or  tubercular  joint  disease.  A  similar  result 
also  followed  joint  contusion  in  some  cases  where  non- 
inoculated  animals  had  been  simply  living  in  contact 
with  animals  that  had  been  rendered  tuberculous. 
These  apparently  healthy  animals  developed  a  tuber- 
cular joint  affection.  A  like  inquiry,  however,  in 
animals  that  had  not  been  so  associated,  led  to  none 
but  a  passing  local  disturbance.  Dr.  Baumgarten§ 
recently  introduced  into  the  anterior  chamber  of  the 
eye  of  a  healthy  rabbit  a  drop  of  fresh  blood  taken  from 
a  rabbit  afflicted  with  general  artificial  tuberculosis. 
In  two  or  three  weeks  an  eruption  of  tubercles  appeared 
on  the  iris  just  as  in  Cohnheim's  cases. 

*  An  epitome  of  these  exoerimenls  will  be    found  in   Dr.  C.    Hueter's 
"  Grundriss  der  Chirurgie."   Leipsig,  1880,   vol.  i.  p.  270. 

f  "  Centralblatt  f.   Med.  Wissensch.,"  No.  18,  1881.  p.  322. 
\  "  Experimented     und    hisfologische     Untersuchungen,    uber    die 
Enstehung  und    Ursachen  der    Scroph.    und    Tuberk.    Gelenkleiden. ' 
Stuttgart,   1880. 

§  Centralblatt  f.  Med.    Wissensch,  No.  15,  1 88 1,  p.  274. 


40  A   DEFINITION   OF   SCROFULA 

CHAPTER   V. 

A   DEFINITION   OF   SCROFULA. 

I  would  define  scrofula  as  a  tendency  in  the  indi- 
vidual to  inflammations  of  a  peculiar  type,  the  distinct- 
ive features  of  such  inflammations  being  as  follows  : — 
They  are  usually  chronic,  apt  to  be  induced  by  very 
slight  irritation,  and  to  persist  after  the  irritation  that 
induced  them  has  disappeared.  The  exudations  in  these 
processes  are  remarkable  for  their  cellular  character  and 
for  the  large  size  of  some  of  those  elements.  Such 
exudations  also  show  a  remarkable  tendency  to  resist 
absorption  and  to  linger  in  the  tissues,  the  affected 
area  becoming  rapidly  non-vascular.  Among  the  com- 
non  products  of  these  inflammations  are  giant  cells, 
and,  if  a  certain  stage  of  the  process  be  reached,  tuber- 
cles. The  tendency  of  the  process  is  to  degenerate, 
not  to  organize,  and  the  degeneration  usually  takes  the 
form  of  caseation.  At  the  same  time  these  inflamma- 
tions have  a  tendency  to  extend  locally  and  infect 
adjacent  parts,  and  their  products  present  certain  pecu- 
liar properties  when  inoculated  upon  animals.  Lastly, 
a  great  feature  of  all  these  processes  in  this  —  they 
tend  to  commence  in  and  to  most  persistently  involve 
lymyhatic  tissue :  an  implication  of  this  tissue  being  a 
conspicuous  feature  in  every  case  of  scrofulous  disease. 

The  tendency  to  this  peculiar  form  of  inflammation 
may  be  called,  if  so  wished,  a  diathesis,  or,  more  defin- 
itely, the  scrofulous  diathesis. 

I  do  not  propose  to  discuss  here  all  the  points  of  this 
definition.  Some  of  the  special  features  of  scrofulous 
inflammation  have  often  been  considered  in  dealing 
with  the  subject  of  tubercle,  and  among  these  the 
inoculability  of  the  products  of  such  inflammations  has 
been  referred  to.  The  histology  of  the  process,  the 
peculiarities  of  its  exudations,  its  mode  of  decay,  and 
its  relation  to  adjacent  tissues,  will  all  be  fully  treated 
of  in  the  section  that  deals  with  the  pathology  of 
lymphatic  gland  disease.    There  is  only  occasion,  there- 


A  DEFlNITIOxNT   OF  SCROFULA.  41 

fore,  to  consider  in  the  present  place  these  few  remain- 
ing features,  viz.,  1.  The  chronicity  of  the  scrofulous 
process.  2.  The  slight  irritation  that  may  induce  it. 
3.  Its  tendency  to  extend  locally  and  by  continuity  of 
tissue :  and,  4.  The  remarkable  and  constant  manner  in 
which  it  involves  lymphatic  tissue. 

I.  The  chronicity  of  all  scrofulous  manifestations  is 
well  known.  The  gland  affections  are  slow  in  their 
progress,  often  extremely  slow,  so  that  their  duration 
may  be  estimated  more  often  by  years  than  by  months. 
In  like  manner,  the  classical  bone  and  joint  affections 
of  the  scrofulous  are  essentially  chrome.  The  same 
leisurely  course  can  be  observed  in  the  skin  eruptions 
and  in  the  disorders  of  the  mucous  membranes.  If 
acute  inflammatory  changes,  do  occur  in  the  subjects  of 
scrofula,  such  changes  are  nearly  always  accidental,  and 
may  be  regarded  as  complications  of  the  process  that 
are  by  no  means  either  usual  or  necessary.  Indeed, 
those  who  present  scrofula  in  a  marked  degree  seem 
singularly  little  prone  to  acute  inflammations  of  any 
kind.  Their  tissues  seem  to  react  rather  with  the  utmost 
torpidity  under  the  inflammatory  process.  And  in  other 
affections  that  are  only  incidentally  associated  with 
inflammation  a  like  tendency  to  a  chronic  action  can 
often  be  observed.  For  example,  I  have  in  one  or  two 
cases  seen  herpes  zoster  in  a  scrofulous  child  assume  a 
very  tedious  course,  and  induce  an  amount  of  sluggish 
suppuration  not  usually  met  with  in  that  neurosis. 

2.  In  treating  of  the  gland  affections  in  scrofula  I 
shall  draw  attention  to  the  trifling  character  of  the  peri- 
pheral lesion  that  is  often  sufficient  to  set  up  the  disease 
in  the  absorbents.  A  slight  ulcer  within  the  mouth, 
defects  in  dentition,  a  trifling  eczema  behind  the  ears,  an 
ophthalmia,  are  all  sufficient  to  induce  a  considerable 
gland  disorder :  and  that  disorder  will  persist,  and  indeed 
progress,  after  the  initial  disturbance  has  entirely  dis- 
appeared. So  in  bone  and  joint  affections  and  in  spinal 
caries  one  is  often  surprised  at  the  slight  traumatism  that 
may  induce  a  very  severe  and  extensive  morbid  change. 
A  trifling  exposure  to  cold,  that  in  a  healthy  child  would 
have  little  or  no  effect,  suffices  often  to  arouse  an  obsti- 


42  A   DEFINITION   OF   SCROFULA. 

nate  conjunctivitis,  or  catarrh,  or  ulceration  of  a  mucous 
membrane,  that  persists,  aud  for  a  long  while  resists  treat- 
ment. Cold  abcess,  again,  often  makes  its  appearance 
after  the  most  insignificant  injuries  ;  and,  indeed,  a  large 
number  of  scrofulous  maladies  have.an  origin  so  obscure 
that  they  are  regarded  as  spontaneous  in  their  nature. 
In  the  subjects  of  scrofula  there  appears  to  be,  indeed,  a 
remarkable  vulnerability  of  tissue,  a  strange  proneness  to 
lapse  into  a  condition  of  disease  after  irritations  usually 
regarded  pathologically  as  of  no  moment.  This  vulner- 
ability of  the  tissues  has  assumed  a  conspicuous  place  in 
the  descriptions  of  scrofula  advanced  by  certain  patholo- 
gists. Virchow  assigns  to  it  a  prominent  position  in  the 
pathogenesis  he  proposes  for  the  disease,  and  many 
others  have  regarded  it  as  a  still  more  essential  factor. 
Recently  M.  Paul*  has  made  this  inherent  weakness  of 
scrofulous  structures  a  feature  in  the  diagnosis  of  the 
affection,  and  would  have  us  recognise  a  class  of  scrofu- 
lous person  from  the  manner  in  which  the  puncture  in 
the  ears  for  ear-rings  takes  on  unhealthy  action,  and  leads 
to  linear  scars,  fissures,  and  similar  deformities.  There  are 
certain  animals,  such  as  the  rabbit  and  guinea-pig,  in 
which  caseous  (or,  as  it  may  be  fairly  called,  scrofulous") 
inflammation  is  very  common  ;  and  it  is  remarkable  that 
in  these  animals  that  form  of  inflammation  is  often 
induced  by  injuries  of  a  comparatively  trifling  nature. 
Too  extensive  inferences  must  not  be  drawn  from  the 
vulnerability  of  tissue  in  the  scrofulous.  It  is  not,  for 
example,  to  be  inferred  that  any  constant,  or  even 
common  relation  exists  between  the  severity  of  the  ini- 
tial lesion  and  that  of  the  subsequent  disease.  It  is  only 
maintained  that  the  tissues  of  the  scrofulous  are  apt  to 
react  with  an  almost  characteristic  readiness  to  disturb- 
ing causes  that  in  the  healthy  would  rank  as  insigni- 
ficant. 

3.  The  tendency  of  the  scrofulous  process  to  extend 
locally  is  a  very  distinct  feature  of  the  disease,  and  is 
apparent  in  most  of  its  manifestations.     In  lupus  this 

*  Sur  un  nouveau  Signe  de  la  Scrofule  fourni  par  les  Boucles  d'Oreille. 
"L'union  Medicate,"  Feb.  26,  1881,  et  seq. 


A   DEFINITION   OF   SCROFULA.  43 

tendency  is  very  conspicuous,  and  forms,  indeed,  one  of 
the  characteristics  of  that  affection.  The  morbid  process 
can  be  observed  to  deliberately  extend,  and  to  invade 
the  adjacent  parts  in  a  progressive  manner.  In  some 
cases  this  extension  may  be  considerable  and  very  wide- 
spread. I  have  now  under  my  care  a  girl  of  16  with 
lupus  non  exedens,  that  has  involved  the  whole  of  the 
right  upper  extremity,  and  has  produced  such  contrac- 
tion as  to  render  the  limb  useless.  The  process  has 
spread  into  the  neck,  and  involved  nearly  the  whole  of 
both  sides  of  it,  and  over  one  of  the  lower  extremities 
a  like  extensive  lupoid  change  has  occurred  in  the  inte- 
guments. One  is  familiar  also  with  the  very  deliberate 
manner  in  which  certain  scrofulous  ulcers  will  extend 
in  spite  of  any  but  the  most  vigorous  treatment,  spread- 
ing not  infrequently  in  a  manner  as  distinct  as  is  observed 
in  certain  ulcers  in  the  tertiary  syphilitic.  In  cases  also 
where  the  skin  becomes  undermined  about  a  sinus — such 
a  sinus  as  may  form  after  the  breaking  of  a  gland  abscess 
— it  is  remarkable  to  observe  how  in  some  instances  that 
undermining  will  extend.  The  undermined  integument 
is  thin  and  purplish,  and  where  it  joins  the  healthy  skin 
a  little  subcutaneous  induration  can  often  be  felt.  This 
induration  represents  the  spreading  scrofulous  process, 
and  it  is  by  its  ultimate  breaking  down  that  the  process 
of  undermining  gradually  extends.  Retained  pus  may 
assist  in  bringing  about  this  condition,  but  if  so  it  acts 
only  as  a  very  feeble  auxiliary ;  for  the  undermining  of 
the  skin  may  extend  in  cases  where  the  pus  has  perfectly 
free  vent,  and  where  elaborate  drainage  is  carried  out. 
Rather  is  it  due  in  the  majority  of  cases  to  a  gradual 
extention  of  a  scrofulous  process  in  the  subcutaneous 
tissue,  fostered  and  augmented,  no  doubt,  by  unhealthy 
changes  already  in  action ;  but  yet  to  such  an  extent  is 
it  a  new  morbid  process  that  the  treatment  of  skin  so 
undermined  becomes  very  different  from  the  treatment 
of  that  sapped  by  simple  suppuration.  Lannelongue 
has  shown  in  a  very  exhautive  manner  how  a  cold 
abscess  extends,  how  its  wall  presents  an  active  scrofu- 
lous process  and  an  abundant  deposit  of  perfect  tuber- 
cles, how  this  wall  gradually  degenerates  and  breaks 


44  A   DEFINITION   OF   SCROFULA. 

down  into  the  abscess  cavity  on  the  one  hand,  while, 
on  the  other,  it  slowly  invades  the  adjacent  tissues  with- 
out line  or  barrier,  and  how  it  is  by  the  extension  of 
this  invading  wall  that  the  abscess  cavity  enlarges. 

The  same  condition  holds  good  with  regard  to  the 
bone  affections  of  the  scrofulous,  and  is  well  seen  in 
caries.  Here  the  diseased  process  spreads  leisurely  and 
deliberately,  unlimited  by  any  barrier  of  healthier  action. 
The  morbid  condition  shades  off  so  gradually  into  the 
as  yet  unaffected  bone,  that  it  is  often  difficult  to  say 
where  disease  ends  and  sound  bone  begins.  M.  Lanne- 
longue  has  compared  the  spreading  of  this  disease  in 
bone  to  its  spreading  in  the  case  of  cold  abscess,  and 
regards  the  two  examples  of  tissue  invasion  as  identical. 
In  speaking  of  gland  affections  I  shall  have  occasion  to 
deal  at  some  length  with  this  feature  of  local  extension 
in  scrofulous  disease,  and  shall  show  how  the  process 
may  creep  from  one  gland  to  another  independent  of 
any  new  or  abiding  source  of  peripheral  irritation  ;  how 
one  gland  may,  as  it  were,  infect  another,  and  how  the 
path  of  infection  is  along  connecting  lymphatic  vessels. 

Cases  are  sometimes  met  with  where  local  extension 
by  means  of  the  lymphatics  has  been  very  considerable, 
and  where  disease  in  widely  separate  parts  has  been 
connected  by  continuity  of  tissue.  For.  example,  Dr. 
Pye  Smith,*  under  the  title  of  "  Primary  Caseous 
Degeneration  of  Lymphatic  Glands,"  describes  the  case 
of  a  woman,  aged  47,  in  whom  caseous  inflammation 
commenced  in  the  lymphatic  glands  of  the  mediastina, 
set  up  apparently  by  a  bronchitis.  The  process  spread- 
ing upwards  from  the  bronchial  glands  reached  the  neck 
and  involved  both  sides  of  it.  Extending  in  the  oppo- 
site direction  it  reached  the  glands  of  the  omentum  and 
mesentery,  so  that  the  whole  of  the  diseased  parts 
formed  one  continuous  series.  Dr.  Hilton  Fagge  f 
records  a  like  case  occurring  in  a  woman  aged  35.  Here 


*  "  Trans.  Path.  Soc,"  London,  vol.  xxvi.  1875,  p.  202. 

f "  Trans.  Path.  Soc,"  London,  vol.  xxv.  1874,  p.  235;  see  also 
similar  case  under  title  of  "  Fibroid  Disease  of  Heart,"  on  p.  72  of  same 
volume. 


A   DEFINITION   OF   SCROFULA.  45 

the  gland  mischief  commenced  in  the  left  groin,  and 
from  that  spot  a  cotinuous  chain  of  large  case- 
ous glands  were  traced  up  along  the  front  of  the  spine 
into  both  sides  of  the  neck.  The  spreading  here  by 
continuity  of  tissue  was  deliberate  and  definite.  Some 
of  the  gland  masses,  especially  those  about  the  trachea, 
were  moreover  very  large.  Dr.  Goodhart  *  records  a 
case  in  some  respects  still  more  interesting.  The 
patient,  a  man  aged  22,  suffered  from  pulpy  degenera- 
tion of  the  right  knee,  that  ultimately  required  ampu- 
tation. Death  resulted,  and  at  the  post-mortem  it  was 
found  that  the  glands  in  the  right  Scarpa's  triangle 
were  involved,  and  from  thence  a  continuous  chain  of 
diseased  glands  could  be  followed  up  along  the  psoas 
muscle,  along  the  front  of  the  spine,  about  the  root  of 
the  lungs,  and  so  up  into  the  neck,  especially  implica- 
ting the  glands  of  the  right  side.  Here,  then,  there 
existed  a  continuity  of  disease  from  the  knee  to  the 
posterior  triangle  of  the  neck.  Little  more  need  be 
said  upon  this  subject.  Suffice  it  to  state  that  the 
same  tendency  to  local  spreading  or  infection  is 
exhibited  in  other  scrofulous  affections,  notably  in 
the  scrofulous  ulcer  of  mucous  membranes  and  in 
that  local  tuberculosis,  that  quasi-scrofula  that  pre- 
cedes the  eruption  of  general  tuberculosis  in  the 
inoculation  experiments  in  animals.f  On  this  mat- 
ter, considered  in  its  entirety,  we  would  fully  endorse 
trie  observation  of  M.  Kiener  as  to  scrofulous  affec- 
tions, that  "  chaque  foyer  exerce  sur  les  tissus  environ- 
nants  une  action  infectieuse  de  voisinage,  d'ou  r6sulte 
la  formation  de  nouveaux  foyers."  ^ 

4.  The  marked  implication  of  lymphatic  tissues  in 
all  the  manifestations  of  scrofula  is  the  feature  which, 
of  all  isolated  attributes,  I  would  urge  to  be  the  one 
most  significant  of  the  process  From  the  earliest  days 
of  medicine,  scrofula  has  been  associated  in  some  way 


*  "Guy's  Hospital  Reports,"  vol.  xviii,  1873,  p.  401. 
fSee  "The  Artificial   Production  of  Tubercle,"  by  Dr.  Wilson  Fox. 
London,  1868. 

\L  Union  Medicate,  Feb.  22,  1881,  p.  320. 


46  A   DEFINITION   OF   SCROFULA. 

or  another  with  the  lymphatic  system  ;  and  such  asso- 
ciation is  no  matter  of  wonder  when  the  remarkable 
tendency  to  lymphatic  gland  enlargement  in  the  scrofu- 
lous is  borne  in  mind.  The  older  authors  conceived 
some  humor  or  acrid  matter  in  the  lymph  that  caused 
it  to  coagulate  in  the  glands.  Others  maintained  that 
fluid  to  be  of  too  great  consistence.  Others,  that  the 
lymphatic  vessels  were  at  fault,  or  the  glands  were  so 
ill  constructed  as  to  prevent  the  lymph  from  passing 
through.  In  more  recent  times,  the  association  of 
scrofula  with  the  lymphatic  tissues  has  assumed  a  less 
indefinite  outline.  Bell  and  Hufeland  considered  that 
scrofula  was  due  essentially  to  a  certain  weakness  or 
atony  of  the  lymph  system.  Virchow  adopts  a  very 
similar  view,  and  ascribes  the  disease  to  a  great  extent 
to  an  incompleteness  in  the  structure  of  the  lymphatic 
glandular  apparatus.  Birch-Hirschfeld,*  in  alluding  to 
this  latter  tissue  weakness,  considers  that  it  may  not  be 
unlike  that  hereditary  defect  in  the  vascular  apparatus 
that  marks  haemophilia.  Villemin  f  regards  scrofula  as 
due  to  a  morbid  irritability  of  what  he  terms  the  lym- 
phatico-connective  system — a  tissue  system  composed 
of  the  connecting  structures  of  the  body,  and  the  sys- 
tem of  lymphatic  channels  with  which  those  tissues  are 
in  such  immediate  and  direct  relation.  He  ascribes  the 
chronicity  of  the  superficial  manifestations  of  scrofula, 
their  tendency  to  extend,  their  inclination  to  involve 
deeper  parts,  to  implication  of  this  system  of  tissues, 
and  regards  such  implication  as  the  essential  feature  of 
the  whole  process.  Like  views  have  been  advanced  by 
others.  To  come,  however,  to  matters  more  of  detail. 
The  first  point  to  be  noted  is  the  great  tendency  to 
gland  enlargement  in  all  strumous  disorders.  This  fact 
alone  establishes  a  remarkable  alliance  between  scrofula 
and  the  anatomical  element,  lymph  tissue.  But  if 
other  scrofulous  affections  are  observed  in  detail,  the 
same  alliance,  and  indeed  a  still  closer  one,  becomes 
obvious. 


*Ziemssen's  "  Cyclopaedia  of  Medicine,"  vol.  xvi,  p.  763. 

f  "  Scrofulisme  et  Tuberculose."    U  Union  Medicate,  March  29,  188 1. 


A   DEFINITION   OF   SCROFULA.  47 

One  of  the  commonest  manifestations  of  scrofula  is 
the  enlarged  tonsil,  and  it  is  needless  to  observe  that 
the  tonsil  is  simply  a  mass  of  lymphoid  or  adenoid  tis- 
sue. Scrofulous  pharyngitis  is  merely  a  caseous  inflam- 
mation of  the  lymphoid  tissue  of  the  pharynx,*  the 
scrofulous  ulcer  of  the  intestine  has  its  original  seat  in 
the  adenoid  structures  of  the  gut,  the  tubercular  ulcer 
of  the  larynx  begins  in  the  lymph  follicles  of  the  part,f 
and  a  like  intimate  structural  relation  has  been  shown 
by  Rindfleisch  ^  to  exist  in  tubercular  ulcers  of  the 
bronchial  mucous  membrane.  And  in  the  other  affec- 
tions of  mucous  surfaces  common  in  the  scrofulous, 
such  as  ozcena,  coryza,  and  vaginitis,  there  are  strong 
reasons  for  believing  that  a  considerable  implication  of 
the  lymphatic  structures  exists.  Mr.  Greig  Smith,  §  in 
an  interesting  and  most  valuable  contribution  to  the 
pathology  of  strumous  bone  disease,  alludes  to  the 
important  part  the  red  marrow  plays  in  these  affec- 
tions ;  and  holding  in  mind  the  intimate  connection 
that  undoubtedly  exists  between  this  marrow  and  the 
general  lymphatic  apparatus  of  the  body,  he  ventures 
to  speak  of  such  bone  disease  as  essentially  a  lympha- 
denitis. When  one  comes,  however,  to  microscopic 
investigation,  the-  evidence  as  to  this  relationship 
proves  more  than  sufficient.  I  would  urge  that  lym- 
phatic structures  of  some  kind,  no  matter  whether  ves- 
sels, channels,  or  adenoid  tissues,  are  essential  to  the 
formation  of  tubercle,  and  that  this  tissue  forms  as 
much  the  basis  of  tubercle  as  epithelium  does  of  epi- 
thelioma. Lymphatic  tissue  is,  of  course,  almost  uni- 
versal in  its  distribution,  but  it  is  the  very  prominent 
implication  of  that  structure  that  is  so  marked  a  feature 
in  tuberculosis.  If  the  tubercle  formed  in  the  artificial 
tuberculosis  of  animals  is  to  be  regarded  as  in  any  way 
a  typical  product,  then  must  it  be  acknowledged  that 
its  origin    is    almost   exclusively   from   lymph   tissue. 


*  Wendt.  .  "  Ziemssen's  Cyclopaedia,"  vol.  vii,  p.  75. 

+  Dr   Curnow.     "  Gulstonian  Lectures."     Lancet,  vol.  i,  1879,  p.  510. 

1  Loc.  cit.,  "Ziemssen's  Cyclopaedia,"  p.  663. 

§  "  Reprint  from  the  British  Royal  Infirmary  Reports,"  1878-79,  p.  99. 


43  A   DEFINITION   OF   SCROFULA. 

Such  tubercles,  when  met  with  in  the  lungs,  commence 
merely  ars  nodular  enlargements  of  the  adenoid  tissue, 
that  normally  exist  around  the  bronchi  and  the  blood- 
vessels of  the  part.  The  whole  process  concerns  the 
lymphatics.  If  the  matter  be  introduced  into  the 
pleural  cavity,  the  first  evidence  of  the  pleuritis 
induced  shows  itself  about  the  surface  lymphatics. 
If  the  so-called  tubercular  process  extends  to  the  lungs, 
that  extension  is  by  the  lymphatics  (Klein).  If  it 
extends  within  the  lungs,  it  is  by  the  lymphatics. 
Wilson  Fox  has  shown  the  same  extraordinary  impli- 
cation of  lymphatic  structures,  and  indeed  in  his 
experiments  with  injections  into  the  subcutaneous 
tissues,  the  whole  progress  of  the  malady  is  to  be 
followed  by  following  the  lymphatics.  He  strongly 
insists  upon  the  lymphatic  structure  of  tubercle,  points 
out  its  origin  from  lymphatic  tissues,  and  suggests  that 
it  may  be  due  to  some  peculiar  morbid  disposition  in 
those  tissues.* 

The  origin  of  tubercle  from  the  perivascular  lymphat- 
ics has,  I  think,  been  very  clearly  demonstrated,  espe- 
cially with  regard  to  the  blood-vessels  of  the  pia  mater. 
Cornil  and  Ranvier  f  give  an  excellent  drawing  to  show 
the  development  of  tubercle  from  a  lymphatic  vessel 
in  a  case  of  tubercular  ulcer  of  the  intestine.  Rind- 
fleisch  X  has  shown  how  in  the  lung  the  tubercular 
ulcer  of  the  bronchus  spreads  locally  by  invading  the 
lymph  channels  of  the  part.  In  dealing  subsequently 
with  the  giant  cells  of  tubercle,  I  shall  endeavor  to 
show  that  these  bodies  can  only  appear  when  lymphatic 
channels  or  tissues  are  provided  as  an  anatomical  basis, 
and  shall  indeed  hope  to  prove  that  they  are  merely 
peculiar  lymph  coagula. 

There  are  other  points  eminently  suggestive  of  a 
serious  implication  of  the  lymphatic  apparatus  in  the 
scrofulous.     Dr.  Grancher  §  was  fortunate   enough  to 


*  Loc.  cit. ,  p.  29. 

\Loc.  cit.,  p.  634,  fig.  255. 

\Loc.  cit.,  p.  663. 

§  "Loc.  cit.,  Dictionnaire  Encyclopedique, "  p.  311. 


A   DEFINITION    OF   SCROFULA.  49 

obtain  sections  of  the  hypertrophied  upper  lip  from  a 
scrofulous  child.  This  deformity,  which  is  considered 
by  some  as  very  typical  of  scrofula,  is  no  doubt  due 
merely  to  irritation  of  the  part  by  previous  local  mis- 
chief, usually  by  unwholesome  discharges  from  the 
nose.  This  hypertrophy  showed  on  examination 
merely  a  great  dilatation  of  the  lymphatic  capillaries  of 
the  subdermic  tissues,  with  thickening  of  their  walls. 
In  some  places  the  greatly  distended  spaces  were  partly 
blocked  by  an  accumulation  of  lymph  and  coagulated 
fibrin.  Dr.  Curnow,  *  speaking  of  inflammatory  affections 
of  the  lymphatic  vessels,  says,  "  With  reticular  lym- 
phangitis I  am  inclined  to  include  the  acute  swellings 
of  the  lips  and  tip  of  the  nose,  which  is  so  common  in 
strumous  people,  and  the  red  and  painful  patches  in  the 
vicinity  of  eczematous  eruptions  on  the  nose,  lips,  and 
ears,  inasmuch  as  it  is  only  where  lymphatic  networks 
are  especially  abundant  that  such  cedematous  swellings 
occur."  Hueterf  considers  that  the  sodden  and  pasty 
condition  of  the  skin  seen  sometimes  in  strumous  sub- 
jects may  be  due  to  a  permanently  dilated  state  of  the 
lymphatic  vessels,  and  such  a  suggestion  would  appear 
extremely  probable.  Occasionally,  in  delicate  scrofu- 
lous children  there  is  a  strange  tendency  for  wheals  to 
develop  on  the  most  trivial  provocation.  Dr.  Thomas 
Barlow^:  records  the  case  of  an  infant  in  this  condition 
in  whom  a  slight  scratch  or  even  friction  of  the  skin 
brought  out  a  wheal  almost  immediately.  That  these 
whe'als  are  to  be  explained  by  an  injury  to  greatly 
enfeebled  lymphatic  vessels  and  channels  appears  to  be 
very  probable,  and  to  be  aptly  compared  to  the  haemor- 
rhages that  may  occur  from  slight  lesions  in  certain 
enfeebled  conditions  where  a  weakness  of  the  vascular 
capillaries  is  imagined  to  exist. 

What  is  actually  the  anatomy  and  physiology  of  the 
lymph   apparatus   in  the  scrofulous  is  still  a  matter  of 

*  "  Loc.  cit.,"  p.  508.     Dr.  Curnow  describes  the  lymphatics  as  being 
especially  numerous  at  parts  where  skin  join,  mucous  membrane, 
■f  "  Grundriss  der  Chirurgi,"  1881,  p.  266. 
\  "Trans.  Clinical  Soc,"  London,  vol.  x.  1877.  p.  197, 

4 


50  SCROFULA  AND   PHTHISIS,   AND   THE 

conjecture,  but  that  this  apparatus  presents  a  strange 
vulnerability,  a  remarkable  tendency  to  encourage  and 
invite  disease  in  those  who  present  the  scrofulous  dia- 
thesis, must,  I  think,  be  allowed. 


CHAPTER  VI. 

SCROFULA  AND   PHTHISIS,   AND   THE   ANTAGONISM 
BETWEEN    SCROFULOUS   DISEASES. 

The  relation  between  these  two  affections  has  been  a 
subject  for  endless  dispute,  and  is  still  under  discussion. 
The  matter  has  been  debated  from  both  a  clinical  and 
a  pathological  standpoint,  and  it  must  be  confessed  that 
the  most  opposite  opinions  have  been  supported  by  no 
small  amount  of  valuable  evidence. 

I  might  at  once  state  the  particular  opinion  I  venture 
to  urge  on  this  matter.  I  believe  that  scrofula  and 
phthisis  are  due  to  the  same  morbid  process,  that 
phthisis  may  be  regarded  as  scrofula  of  the  lung  in  like 
manner  as  a  scrofulous  lymphatic  mass  may  be  regarded 
as  phthisis  of  a  gland.  I  would  acknowledge  no  rela- 
tionship between  the  two  other  than  that  of  their  iden- 
tity and  the  actual  sameness  of  the  morbid  action  in  the 
two  diseases ;  and  would  entertain  no  such  alliance 
between  them  as  that  of  cause  and  effect,  or  soil  and 
seed,  of  primary  disease  and  secondary  disease,  all  of 
which  relations  have  from  time  to  time  been  insisted 
on.  The  observation  of  a  few  clinical  facts  are  suffi- 
cient to  impress  one  with  the  intimacy  that  exists 
between  these  two  diseases.  They  both  occur  not  infre- 
quently in  the  same  kind  of  delicate  person.  I  do  not 
mean  that  such  individuals  have  a  distinct  physiog- 
nomy. They  are  classed  with  the  vague  mass  of  the 
delicate,  but  present  certain  vague  marks  of  frail  health 
that  are  common  both  to  those  who  exhibit  scrofula 
and  to  those  who  are  phthisical.     The  description  of  a 


ANTAGONISM  BETWEEN  SCROFULOUS  DISEASES.     5  I 

child  with  "  a  phthisical  tendency,"  as  given  in  many 
text-books,  very  fairly  accords  with  what  is  known  as 
the  sanguine  or  erethic  form  of  scrofula.  Then,  again, 
in  the  etiology  of  the  two  affections  there  is  a  remark- 
able unanimity  when  tendencies  that  may  be  regarded 
as  purely  local  are  excluded.  The  same  general  causes 
that  predispose  to  phthisis,  predispose  to  scrofula,  a 
fact  that  Ruehle*  has  pointed  out  in  some  detail.  The 
same  observer  also  states  that,  as  a  general  rule,  where 
scrofula  is  very  prevalent  phthisis  is  also  common.  To 
this  latter  rule  there  are  of  course  exceptions;  but  I 
think  that  the  different  proportions  in  which  the  two 
diseases  exist  in  certain  parts  of  the  world  can  be 
explained  by  conditions  that  in  one  case  lead  rather  to 
the  surface  ailments  of  scrofula,  and  in  the  other  to 
general  pulmonary  disorders,  f 

A  simple  example  of  a  common  cause,  leading  in  one 
case  to  scrofula  and  in  another  to  phthisis  is  afforded 
by  measles.  It  is  well  known  that  measles  is  frequently 
followed  by  cervical  gland  enlargements,  induced,  it  is 
supposed,  by  the  coryza  that  accompanies  it,  and  that 
it  may  act  as  the  exciting  cause  of  more  extensive  stru- 
mous disease  in  those  already  predisposed  to  scrofula. 
Measles  also— as  Ruehle  ^  has  shown — has  often  an 
intimate  concern  in  the  etiology  of  consumption,  and 
may  be  considered  in  this  instance  to  act  through  the 
bronchitis  with  which  it  is  attended.  Here,  then,  the 
same  malady  in  two  different  situations  excites  the 
same  disease  in  corresponding  parts ;  for  it  is  hard  to 
conceive  special  conditions  for  the  mucous  membrane 
of  the  lung  that  do  not  also  hold  good  for  the  mucous 
lining  of  the  nose  and  pharynx.  Moreover,  in  the  mat- 
ter of  heredity  these  two  disorders  are  often  seen  to  be 


*  "  Ziemssen's  Cyclopaedia  of  Medicine,  Art.  Pulmonary  Consump- 
tion," vol.  v.  p.  496. 

•j-  Dr.  Thaon,  who  maintains  the  identity  of  scrofula  and  phthisis,  and 
speaks  of  phthisis  and  scrofula  of  the  lung,  has  drawn  attention  to  certain 
local  and  climacteric  influences  that  lead  to  the  unequal  distribution  of 
scrofula  and  phthisis  in  certain  part*.  L'  Union  Mcdirale,  vol.  xxxi.  1881. 
p.  40.  ; 

\   "  Loc.  cit.,"  p.  504. 


52  SCROFULA  AND   PHTHISIS,   AND   THE 

interchangeable.  A  phthisical  parent  may  beget  scrof- 
ulous children,  and  a  scrofulous  parent  phthisical  off- 
spring. Or  in  a  given  family  with  a  history  of  what 
might  be  termed  a  tubercular  taint,  some  of  the  children 
may  become  scrofulous,  while  others  are  phthisical,  and 
the  rest  perhaps  present  simply  that  delicacy  of  health 
that  we  know  might  lead  to  one  or  other  of  those 
diseases.* 

When,  in  the  next  place,  one  comes  to  compare  the 
morbid  changes  in  consumption  with  those  in  scrofula, 
to  compare  a  phthisis  of  the  lungs,  on  the  one  hand, 
with  (let  us  say)  a  scrofulous  gland  on  the  other,  I  think 
it  must  be  owned  that  the  resemblance  is  very  close. 
I  ventured  to  define  scrofula  as  an  inflammation  pre- 
senting certain  distinctive  features,  and  I  would  main- 
tain that  these  very  features  form  also  the  distinctive 
attributes  of  the  phthisical  process.  If  the  definition 
already  given  to  scrofula  can  apply  also  to  phthisis, 
then  phthisis  may  be  thus  described.  It  is  a  process 
usually  chronic,  apt  to  be  induced  by  very  slight  irrita- 
tion, and  to  persist  after  that  irritation  has  disappeared. 
Its  exudations  are  remarkably  cellular  in  character, 
prone  to  resist  absorption,  and  to  linger  in  the  tissues. 
Among  the  common  products  of  the  process  are  giant 
cells,  and  in  certain  cases  tubercle  ;  the  affected  districts 
in  any  case  becoming  rapidly  non-vascular.  The 
tendency  of  the  process  is  to  degenerate,  and  such 
degeneration  usually  assumes  the  form  of  caseation. 
The  process,  moreover,  has  a  tendency  to  extend  locally 
and  infect  adjacent  parts  ;  its  products  also  produce 
certain  results  when  inoculated  in  animals. 

This  is,  I  believe,  no  imperfect  description  of  phthisi- 
cal change,  and  yet  it  is  merely  a.  repetition  of  the 
terms  used  in  defining  scrofula.  The  naked  eye 
changes  in  the  parts  are  very  similar:  The  lungs  and 
the  gland  become  affected  in  certain  spots,  which  spread 
and  fuse.  Caseation  occurs.  The  tissue  breaks  down, 
and  a  cavity  is  produced.     The  destructive  action  is, 

*  Tyler  Smith  well  describes  such  a  family  in  his  work — "Scrofula: 
its  Nature,  Causes,  and  Treatment."     London,  1844,  P-  6. 


ANTAGONISM  BETWEEN  SCROFULOUS  DISEASES.     53 

for  a  time  at  least,  not  limited  by  a  barrier  of  healthier 
action.  In  both  the  gland  and  the  lung,  however,  the 
caseous  mass  may  be  encapsuled  or  become  cretaceous, 
or  the  whole  process  may  be  associated  with  a  great 
development  of  fibrous  tissue  (fibroid  phthisis),  or  lastly, 
cure  may  follow  by  any  one  of  these  less  frequent 
changes.  The  cavities  in  a  phthisical  lung  appear  to 
me  in  no  way  unlike  the  broken  down  spaces  in  articular 
osteitis,  or  the  excavations  in  the  testicle  in  scrofulous 
orchitis,  or  the  purulent  cavity  beneath  the  skin  due  to 
the  breaking  down  of  what  is  known  as  a  scrofulous 
gumma.  The  implication  of  lymphatic  tissue  in  phthisis 
will  be  immediately  alluded  to,  but  here  I  can  but  draw 
attention  to  the  frequent  implication  of  the  bronchial 
glands  in  phthisis,  and  the  absolute  identity  of  such 
glands  with  those  more  superficial  organs  usually 
denoted  scrofulous.  Is  there  any  lung  affection  (apart, 
perhaps,  from  certain  rare  new  growths)  where  the 
glands  are  so  constantly  involved  as  they  are  in  phthisis  ? 
I  imagine  not ;  and  this  fact  alone  appears  to  be  most 
significant.  Moreover,  the  clavicular  and  axillary 
glands  may  be  involved  in  cases  of  phthisis,  and 
present  on  removal  precisely  the  characters  of  scrofulous 
glands. 

In  the  third  place,  brief  notice  may  be  made  of  the 
resemblance  that  exists  in  the  histology  of.  the  two 
affections.  Phthisis,  it  is  very  generally  allowed,  com- 
mences by  an  inflammatory  process,  usually  a  catarrhal 
pneumonia.  Whether  the  catarrh  is  simple,  as  Niemeyer 
would  urge,  or  from  the  very  first  specific,  as  Ruehle 
and  others  insist,  is  a  matter  of  little  moment,  and  a 
question  hardly  to  be  settled  by  reference  to  the 
histology  of  the  disorder.  This  catarrh  is,  as  Niemeyer* 
observes,  equivalent  to  the  initial  inflammation  of  the 
scrofulous,  to  the  inflamed  pharynx  or  conjunctiva  that 
leads  to  gland  disease,  or  to  the  catarrh  that  deepens 
into  a  scrofulous  ulcer.  Its  exudations  are  not  removed, 
and  soon  changes  occur  in  the  walls  of  those  alveoli 
whose  cavities  are  already  filled  with  catarrhal  products. 

*  "  Text-Book  of  Practical  Medicine,"  vol.  i„  1873,  p.  212. 


54  SCROFULA   AND   PHTHISIS,   AND   THE 

I  would  point  out  that  these  changes  considerably 
involve  the  lymphatics.  The  exudation  in  the  alveolar 
wall  consists  at  first  mainly  of  lymphoid  cells.  These, 
as  Grancher  *  says,  are  at  first  ranged  in  linear  rows, 
and  occupy  in  fact  the  interfascicular  spaces  of  the 
tissue ;  such  spaces,  it  is  known,  are  merely  lymph 
channels.  Then,  again,  Rindfleisch  f  connects  these 
changes  in  the  alveolar  wall  with  certain  changes  in  the 
adenoid  structures  about  the  smaller  bronchi  and 
arteries,  and  one  knows  that  the  perivascular  adenoid 
tissue  is  at  least  in  direct  continuity  with  the  lymphatic 
channels  of  the  alveolar  wall  (Klein).  If  the  phthisical 
process  is  rapid — as  in  Phthisis  florida — degeneration 
may  ensue  before  any  giant  cells  or  tubercles  have  been 
met  with  (Ruehle),  the  exudations  and  the  altered  lung 
tissue  simply  becoming  caseous  and  rapidly  disorgan- 
ized. A  precisely  like  condition  occurs  in  certain 
glands  that  caseate  and  break  down  with  great  rapidity. 
In  other  cases  of  phthisis  giant  cells  or  tubercles  may 
appear,  and  their  advent  be  followed  by  caseation  and 
the  usual  mode  of  ending.  Like  conditions  are  com- 
mon in  the  glands.  Lastly,  fibroid  thickening  is  often 
conspicuous  in  the  lung,  especially  in  cases  of  slow 
progress  and  of  little  intensity ;  and  such  a  change,  I 
shall  show,  is  also  met  with  in  some  glands,  although, 
owing  probably  to  the  better  blood  supply  of  the  lung, 
it  is  more  common  in  that  organ  than  in  the  lymphatic 
glands. 

Lastly,  scrofula  and  phthisis  may  occur  in  the  same 
person,  and  a  propos  of  this  one  meets  with  some  singu- 
lar conflicts  of  opinion.  It  will  be  acknowledged,  I 
suppose,  that  scrofulous  patients  may  become  phthisi- 
cal, and  that  phthisical  patients  may  present  scrofula, 
but  can  we  go  so  far  as  to  say  with  Lugol  %  that  "  the 
natural  death  of  the  scrofulous  is  by  consumption,"  or 
with  Hamilton  §  that  "  at  least  9  in  10  of  those  who  die 

*  "  Tuberculose  Pulmonaire,  Archives  de  Phys.,"  1878. 
f  "Ziemssen,  loc.  cit.,"  p.  652. 

I  ' '  Researches  and  Observations  on  the  Causes  of  Scrofulous  Diseases. 
Translation.     London,  1844,  p.  48. 

§  "  Observations  on  Scrofulous  Affections,"  1791,  p.  27. 


ANTAGONISM  BETWEEN  SCROFULOUS  DISEASES.      55 

of  consumption  are  scrofulous  subjects,"  or  even  with 
Ruehle  *  that  scrofula  is  one  of  the  chief  predisposing 
causes  of  phthisis,"  or  with  Rindfleisch  f  that  "  tuber- 
culosis (including  phthisis)  hardly  ever  occurs  except  in 
scrofulous  persons?"  I  imagine  not.  There  appears 
to  be  an  impression  that  if  scrofula  and  phthisis  are  in 
any  way  allied  phthisis  should  be  a  common  cause  of 
death  in  the  scrofulous.  I  know  of  no  two  allied  dis- 
eases where  the  impression  is  so  vividly  maintained  as 
it  is  in  the  present  instances,  and  I  am  unable  to  see 
why  such  a  mode  of  death  should  be  considered  as 
necessary  to  support  any  such  alliance.  Yet  it  is  one 
of  the  most  prominent  arguments  of  those  who  advance 
the  identity  of  the  two  disorders.  I  would,  however, 
say  that  while  scrofula  and  phthisis  are  manifestations 
of  the  same  morbid  process,  I  am  nevertheless  con- 
vinced that  phthisis  is  by  no  means  even  common  in 
the  scrofulous,  and  that  the  bulk  of  such  patients  do 
not  die  of  pulmonary  consumption.  If  scrofulous 
patients  are  so  prone  to  die  of  phthisis  as  some  main- 
tain, then  phthisis  must  be  a  terribly  prevalent  disease, 
for  there  are  few  general  maladies  more  widespread 
than  is  scrofula  ;  and  as  it  is  not  maintained  that  any 
relation  exists  between  the  severity  of  the  strumous 
lesion  and  the  proneness  to  consumption,  all  cases  may 
become  phthisical.  Moreover,  apart  from  this,  if  such 
a  relation  did  exist  one  would  certainly  expect  to  find 
evidences  of  scrofula  in  a  large  percentage  of  phthisi- 
cal patients.  But  investigations  lead  to  quite  an 
opposite  conclusion.  Through  the  kindness  of  Dr.  F. 
J.  Hicks,  medical  officer  to  the  Brompton  Hospital,  I 
was  enabled  to  carefully  examine  57  cases  of  phthisis 
for  evidence  of  any  present  or  past  manifestations  of 
scrofula.  Out  of  the  57  cases  I  found  traces  of  scrofula 
in  only  7  instances,  and  some  of  these  included  trifling 
phases  only  of  the  disease.;}; 

*  "  Loc.   cit.,"  p.  604. 

f  "  Loc.  cit,,"  p.  G39. 

\  The  57  cases  included  patients  of  very  different  ages,  and  were 
taken  simply  in  the  order  in  which  they  came  in  the  wards — 39  were 
females  and  18  males.     Of  the   7  cases  that  showed  any  evidence  of 


56  SCROFULA  AND   PHTHISIS,   AND   THE 

In  332  cases  of  phthisis  examined  post-mortem  by  Mr. 
Phillips  he  found  "  scrofulous  scars  "  in  7  only.*  This 
meagre  result  is  of  course  explained  by  the  fact  that  Mr. 
Phillips  looked  merely  for  one  particular  outcome  of 
scrofula,  viz.,  scars  due  to  glandular  abscess.  In  addition 
to  his  own  observations  he  has  collected  like  statistics 
by  other  surgeons.  These  include  1,078  phthisical 
patients  who  were  examined  post-mortem.  In  only  84 
instances  out  of  this  large  number  was  there  any  evidence 
of  cervical  gland  disease.  Mr.  Kienerf  relates  the  after 
history  of  87  cases  of  scrofulous  bone  and  joint  disease 
with  the  result  that  out  of  this  number  6  only  died. of 
tuberculosis  of  the  lungs  or  meninges.  According  to 
Villemin^:  "  a  considerable  number  of  the  tuberculous 
(including  the  phthisical)  show  neither  vestige  nor  sou- 
venir of  scrofula,"  and  further,  he  states  his  opinion  that 
persons  attacked  by  scrofula  in  their  childhood  do  not 
more  often  become  tubercular  than  do  other  persons. 
Grancher  §  also  strongly  opposes  the  attempt  to  make 
out  that  all  scrofulous  affections  tend  to  end  in  phthisis, 
and  will  not  allow  that  it  is  the  ultimate  manifestation 
of  those  diseases. 

I  maintain,  then,  that  scrofula  and  phthisis  are  identi- 
cal in  their  nature,  but  that  phthisis  is  by  no  means  a 
common  complication — either  immediate  or  remote— of 
the  former  disease.  The  explanation  I  would  offer  of 
this  supposed  discrepancy,  and  indeed  of  the  general 


scrofula,  5  were  females  and  2  males;  3  patients  besides  had  enlarged 
tonsils.  In  several  a  slight  enlargement  of  one  or  two  glands  in  the  neck 
was  detected,  but  in  each  instance  it  was  associated  with  some  recent 
trduble  in  the  pharynx  or  farynx  dependent  on  the  phthisis.  The  7  cases 
with  scrofula  were  as  follows;  ,F.,  aged  39,  caries  of  carpus,  nine  months. 
F.,  24,  gland  abscess  in  neck,  seven  years 'ago.  F.,  24,  ozcena  three 
years  ago,  cervical  gland  disease  two  years  ago  (no  trace  now  left  of 
either  affection).  F.,  35,  caries  of  sternum  two  years  ago;  sinus  exist- 
ing. F.,  19,  extensive  gland  disease  in  neck,  of  six  months'  standing. 
M.,  13,  foot  removed  ten  years  ago  for  disease  of  ankle  joint.  M. ,  25, 
scrofulous  epididymitis. 

*  "  Scrofula  and  its  Treatment."  London,  1846,  p.  75. 

\  "  L'Union  Medicale,  loc.  cit.,"  p.  319. 

%  "Ibid.,"  p.  497. 

§  "Loc.  cit.,  Diet.  Encyclop.,"  p,  325. 


ANTAGONISM  BETWEEN  SCROFULOUS  DISEASES.      57 

relations  between  struma  and  pulmonary  consumption, 
is  the  following. 

There  is  a  decided  antagonism  between  scrofulous 
diseases  of  all  kind.  If  a  patient  has  one  severe  or  even 
well-marked  manifestation  of  scrofula  he  is  not  likely  to 
develop  another  strumous  disease  at  the  same  time. 
Indeed,  the  particular  scrofulous  malady  any  given 
patient  presents  would  appear  to  protect  him  from  any 
other  outcome  of  the  disease  for  at  least  the  time  being. 
The  records  of  the  Margate  Infirmary  for  scrofula  illus- 
trate this  statement  in  a  very  distinct  manner.  From 
fully,  recorded  details  of  509  cases  of  scrofula  in  this 
Institution  I  obtain  these  results* — 248  of  the  cases  were 
males,  and  out  01  this  number  only  27  patients  presented 
more  than  one  grave  manifestation  of  scrofula  at  one 
and  the  same  time.  In  the  remaining  221  cases  there 
was  only  one  grave  outcome  of  struma  in  each  patient. 
261 .  of  the  cases  were  females,  and  among  this  number 
there  were  but  29  affected  with  more  than  one  scrofu- 
lous malady  at  the  time  they  were  under  treatment. 
Placing  the  male  and  female  cases  together,  it  will  be 
seen  that  out  of  the  509  instances  of  scrofula  only  56 
patients  presented  concurrent  scrofulous  affections.  I 
must  explain  that  these  56  cases  include  only  such  as 
present  distinct  and  separate  scrofulous  diseases.  I  have 
omitted  cases  where  two  affections  in  the  same  patient 
stood  to  one  another  in  the  relatien  of  cause  and  effect. 
In  such  cases  one  of  the  affections  was  always  glandu- 
lar, and  as  examples  I  must  cite :  ophthalmia  with  en- 
larged neck  glands,  ozcena  with  a  like  complication, 
ulcers  of  the  foot  with  inguinal  bubo,  and  similar 
instances.  All  such  cases  I  have  excluded,  except  one 
or  two  where  the  gland  disease  had  assumed  consider- 
able proportions.  I  have  also  excluded  cases  where  a 
patient  presented  evidences  of  a  cured  disease  and  an 
active  disease  at  the  same  time.     The  56  cases  include 

*These  cases  were  taken  without  selection,  from  records  kept  by  Mr. 
C.  B.  Waller,  now  of  Sydenham,  and  Mr.  W.  K.  Treves,  of  Margate, 
during  the  periods  they  held  the  office  of  resident  surgeon  to  the  Infirmary. 
These  records  are  singularly  complete,  and  form  an  invaluable  series  of 
cases. 


58  SCROFULA  AND   PHTHISIS,   AND   THE 

instances  of  disease  such  as  these — caries  of  lumbar 
spine,  with  gland  disease  in  the  neck,  disease  of  the 
femur  and  humerus  in  the  same  patient,  disease  of  two 
or  more  joints  at  the  same  time,  or  association  of  such 
bone  and  joint  affections,  with  glandular  enlargements 
in  distant  parts. 

I  think  these  results  are  sufficient  to  show  that  there 
is  an  antagonism  between  scrofulous  affections,  and  that 
it  is  not  usual  for  two  grave  manifestations  of  the  disease 
to  be  active  at  one  and  the  same  time.  Moreover,  it  is 
common  to  observe  one  strumous  disease  subside  or 
improve  when  another  becomes  manifest.  Cases  like  the 
following  illustrate  this  fact : — 

A  little  girl,  aged  14,  with  a  history  of  phthisis  in  her 
family,  had  presented  the  following  succession  of  disea- 
ses. At  the  age  of  6  she  suffered  from  caries  of  the 
tarsus,  leading  to  amputation  of  the  foot  in  a  year's 
time.  When  8  years  old  she  became  afflicted  with 
multiple  subcutaneous  abscesses.  These  in  time  healed, 
and  at  the  age  of  12  she  began  to  present  cervical  gland 
enlargements,  which  had  commenced  to  suppurate  when 
she  came  under  notice.  Female,  aged  23.  When  13 
years  of  age  she  was  the  subject  of  considerable  gland 
disease  in  the  neck.  These  enlargements  persisted  until 
the  age  of  19,  when  she  was  attacked  with  a  lupus  of 
the  face.  On  the  appearance 'of  the  lupus  the  gland 
affection  began  at  once  to  subside.  The  following  case, 
reported  by  Birch-Hirschfeld,  may  well  be  quoted  here: 
— "  I  have  had  for  the  last  three  years  under  my  treat- 
ment a  scrofulous  girl,  12  years  old,  who  from  time  to 
time  is  troubled  with  ophthalmia,  coryza,  and  eczema 
of  the  face  of  great  severity.  In  this  case  I  could  repea- 
tedly observe  painful  tumefaction  to  a  considerable 
extent  of  the  cervical  lymphatic  glands  (especially  near 
the  angles  of  the  jaw),  whenever  these  phenomena 
receded.  As  soon  as  the  first  symptoms  exacerbated, 
an  evident  remission  of  the  glandular  swelling,  and 
especially  of  the  pain  in  it,  took  place,  and,  strange  to 
say,  the  general  condition  always  improved  with  this 
remission.  That  this  was  not  a  mere  coincidence  is 
proved  by  the  repeated  occurrence  of  this  alteration  of 


ANTAGONISM  BETWEEN  SCROFULOUS  DISEASES.     59 

symptons,  it  being  observed  not  less  than  five  times  in 
the  course  of  a  single  year."  *  I  have  notes  also  of  cases 
where  a  marked  improvement  occurred  in  cervical  gland 
disease  on  the  patient  becoming  the  subject  of  hip 
mischief  or  an  extensive  bone  affection,  a  change  hardly 
to  be  expected  when  one  remember  the  further  deteri- 
oration of  health  such  joint  and  bone  affections  must 
imply. 

Now  classing  phthisis  with  scrofulous  diseases  I 
would  maintain  that  the  same  antagonism  is  observed 
in  its  life  history  as  obtains  in  diseases  commonly  desig- 
nated scrofulous.  An  individual  with  scrofula  is  no 
more  likely  to  become  phthiscal  than  a  patient  with 
one  grave  scrofulous  disorder  is  likely  to  develop  an- 
other. Cases  of  course  do  occur,  as  already  allowed, 
where  scrofula  and  consumption  are  met  with  in  the 
same  patient,  but  such  instances  are  not  common. 
Many  of  the  old  authors  recognized  this  antagonism 
between  what  they  termed  external  and  internal  tuber- 
culosis, and  asserted  that  "  so  long  as  gland  disease  is 
active  the  lungs  may  be  regarded  as  safe,  whereas  if 
phthisis  supervenes  the  glands  decrease  rapidly,  and 
may  even  disappear."  f  Recent  writers  have  approached 
the  subject  with  somewhat  more  caution,  but  there  are 
not  a  few  who  allow  this  reciprocity  in  the  two  affec- 
tions. Mr.  Holmes,  for  example,  remarks,  "  moderate 
enlargement  of  glands  in  patients  with  a  family  history 
of  phthisis  is  often  considered  as  a  derivative  or  pre- 
servative against  visceral  mischief,  and  I  must  say  that 
I  incline  to  this  opinion."  $  Dr.  Walsh e,  speaking  of 
the  relation  between  scrofula  and  phthisis,  observes, 
"  The  external  lymphatic  system  on  the  whole  rarely 
undergoes  tuberculization  in  the  phthisical  state.  An 
antagonism,  not  absolute  but  tolerably  well  marked, 
seems  to  exist  between  the  external  and  internal  tuber- 
culizing  processes.     In    corroboration  of    this    I    have 

*  "  Loc.  cit.,"  p.   781. 

f  "On  Scrofulous  Disease  of  External  Lymphatic  Glands,"  by  T. 
Balman.      London,  1852,  p.  417. 

\  "  Surgical  Treatment  of  Diseases  of  Infancy  and  Childhood."  Lon- 
don, 1868,  p.  637. 


60  SCROFULA  AND   PHTHISIS,   AND   THE 

known  the  cervical  and  axiliary  glands  greatly  enlarged 
in  phthisical  people,  rapidly  fall  to  the  natural  size 
without  suppuration  or  symptom  of  any  kind,  while 
pulmonary  tuberculization  rapidly  advanced."  *  If 
phthisis  is  invited  as  it  were  by  any  frailty  of  health, 
and  if  it  is  so  prone  to  attack  the  scrofulous  as  some 
would  have  us  believe,  why  is  the  disease  not  more  fre- 
quent in  the  subjects  of  hip  diseases,  who  lie  bedridden 
for  months  in  the  feeblest  state  of  health,  and  die  at  last ' 
perhaps  of  amyloid  degeneration  of  their  viscera  ?  Why 
is  it  not  more  common  in  the  subjects  of  angular  curv- 
ature, with  the  associated  deformity  of  their  chests  ? 
and  why  do  we  not  more  often  meet  with  it  in  cases  of 
cervical  gland  disease,  where  the  scrofulous  masses  ex- 
tend down  the  trachea,  on  the  one  hand,  or  actually 
reach  to  the  pleura  on  the  other  ?  Such  patients  are,  I 
believe,  protected  by  the  antagonism  that  exists  be- 
tween scrofulous  diseases.  Many  facts  in  the  histories 
of  phthisical  and  scrofulous  families  illustrate  this  point. 
As  examples,  these  cases  may  be  cited  as  a  few  of 
many : — 

A  female,  aged  27,  presented  herself  in  my  out-pa- 
tient rooms  with  extensive  strumous  enlargements  in 
the  neck,  that  had  troubled  her  more  or  less  from  child- 
hood. She  presented  no  traces  of  phthisis.  Her  father 
has  been  phthisical.  She  was  the  youngest  child  but 
one  out  of  a  family  of  seven.  Of  these  the  two  elder 
died  marasmic  in  infancy  ;  the  third,  a  male,  died  at  21 
of  phthisis ;  the  fourth,  a  male,  died  at  22  of  phthisis ; 
the  fifth,  a  female,  died  at  30  of  phthisis ;  and  the 
youngest  member  of  the  family,  a  male,  aged  20,  is  at 
present  in  good  health.  The  patient  is  the  only  one  of 
the  family  who  presented  symptoms  of  scrofula,  and  it 
would  appear  that  this  disease  had  saved  her  so  far 
from  the  fate  of  her  brothers  and  sister.  A  case  as 
marked  was  that  of  a  woman,  aged  46,  also  an  out-pa- 
tient of  mine,  with  suppurating  glands  in  the  neck. 
This  gland  disease  had  troubled  her  since  she  was  11 
years  old,  and  suppuration  had  occurred  so  many  times 

*  "  Diseases  of  the  Lungs."     London,  3d  ed.,  i860. 


ANTAGONISM  BETWEEN  SCROFULOUS  DISEASES.     6l 

that  her  neck  was  covered  with  scars  of  various  dates. 
Her  father  was  a  healthy  man,  and  had  been  killed  by 
an  accident.  Her  mother  died  of  phthisis.  She  had  5 
brothers  and  sisters,  all  of  whom  had  died  of  phthisis, 
with  the  exception  of  one  sister,  who  had  had  gland 
tumors  in  the  neck  and  suppuration  of  the  elbow  joint. 
I  might  add  that  in  these  and  like  cases  I  took  the 
trouble  to  verify  the  patients  statements  as  to  the 
cause  of  death  of  their  relations,  knowing  that  the  less 
educated  of  the  laity  are  apt  to  ascribe  a  very  wide 
sense  to  the  word  "  consumption." 

Lastly,  when  all  traces  of  active  strumous  disease 
have  ceased  to  be  evident,  the  patient  may  become 
phthisical  no  doubt,  but  I  would  urge  that  that  ten- 
dency is  no  more  marked  in  those  who  were  once  scrof- 
ulous, than  it  is  in  those  who  are  simply  of  enfeebled 
health.  The  various  aspects  of  this  relationship  may 
be  perhaps  illustrated  by  an  instance  of  this  kind.  Im- 
agine a  family  of  some  ten  children,  the  offspring  of 
parents  with  a  tubercular  taint.  Some  of  these  child- 
ren become  decidedly  scrofulous,  others  remain  free 
from  any  actual  disease,  and  are  simply  delicate.  Now 
the  former  would  be  less  liable  to  phthisis  than  would 
other  individuals,  while  the  latter  would  be  especially 
prone  to  become  consumptive.  One  would  exhibit  a 
negative,  the  other  a  positive  tendency  to  phthisical 
disease. 

Some  absurd  objections  have  been  raised  to  this 
identity  of  scrofula  and  phthisis  that  may  here  be 
alluded  to.  Some  of  the  older  writers  maintain  a  dif- 
ference because  scrofula  is  less  fatal  than  phthisis ; 
others  because  scrofula  appears  at  an  earlier  age  than  is 
common  for  phthisis,  and  some  few  lay  stress 'upon 
clinical  differences.  Scrofula  tends  to  appear  in  early 
life  on  account  of  the  unusual  activity  af  the  lymphatic 
system  at  that  period,  and  phthisis  somewhat  later,  at  a 
time  indeed  when  the  lungs  are  in  more  active  use, 
when  sedentary  and  perhaps  unhealthy  pursuits  are 
exchanged  for  the  liberty  of  childhood,  when  the  modi- 
fying influences  of  puberty  are  active,  and  the  structu- 
ral  responsibilities   of   adult    life    press  heavily  on  an 


62     SCROFULA  AND  ACUTE  MILIARY  TUBERCULOSIS. 

organism  never  other  perhaps  than  frail.  As  to  clinical 
differences  over  and  above  those  already  referred  to, 
what  arguments  can  be  founded  upon  them  ?  It  has 
actually  been  argued  that  scrofula  and  phthisis  are  not 
identical  because  the  range  of  temperature  is  different 
in  the  two  affections,  because  the  prognosis  is  less  grave 
in  scrofula  than  it  is  in  phthisis,  and  because  the  phthis- 
ical waste  and  become  anaemic  and  sweat  at  night ! 
Those  who  support  these  arguments  would  be  in  a  posi- 
tion to  maintain  that  acute  bubo,  acute  orchitis,  and 
acute  pneumonia  are  all  due  to  different  morbid  pro- 
cesses, because  their  respective  symptoms  are  unlike, 
their  lines  of  temperature  not  the  same,  and  the  prog- 
nosis in  each  case  not  identical.  It  is  needless  to  point 
out  the  fallacy  of  such  reasoning ;  and  a  propos  of  this 
last  comparison  I  would,  on  the  contrary,  assert  that 
scrofula  and  phthisis  are  as  much  manifestations  of  the 
same  morbid  change  as  acute  bubo,  acute  orchitis,  and 
acute  pneumonia  are  outcomes  of  one  single  process — 
acute  inflammation. 


CHAPTER  VII. 

SCROFULA    AND    ACUTE    MILIARY    TUBERCULOSIS. 

Acute  miliary  tuberuluosis  should  be  kept  distinct 
from  those  other  diseases  generally  described  as  tuber- 
culous, just  as  pyaemia,  with  its  multiple  abcesses,  may 
be  kept  apart  from  common  suppuration.  Acute  mili- 
ary tuberculosis  is  an  infective  disease,  a  disease  due  to 
the  dissemination  throughout  the  body  of  some  noxious 
material,  the  nature  of  which  is  not  yet  fully  known. 
It  would  appear,  however,  that  some  pre-existing  case- 
o«s  mass  may  provide  the  infecting  agent,  and  accord- 
ing to  Buhl,  Leudet,  and  others,  such  caseous  masses 
are  seldom  absent  from  the  cadaver  after  death  from 
this  disease.  It  might  fairly  be  compared  to  pyaemia, 
the  only  difference  between  the  two  being  the  nature 


SCROFULA  AND  ACUTE  MILIARY  TUBERCULOSIS.     63 

of  the  poison  and  the  special  local  evidences  it  produces 
■ — on  the  one  hand,  an  eruption  of  abscesses,  on  the 
other,  an  eruption  of  tubercles.  As  scrofula  is  an  affec- 
tion that  leads  almost  constantly  to  caseous  products, 
it  is  no  matter  of  wonder  that  scrofula  has  been  con- 
sidered as  a  primary  cause  of  acute  miliary  tubercluosis. 

It  must  be  understood,  however,  that  scrofula  acts 
only  by  producing  a  caseous  material,  and  that  all  other 
conditions  that  lead  to  caseation  may  be  regarded 
equally  as  causes  of  acute  miliary  tubercluosis.  Why 
that  material  becomes  absorbed  in  some  cases  and  fur- 
nishes a  noxious  infecting  agent,  while  in  others  it 
remains  harmless,  cannot  yet  be  determined.  A  vast 
multitude  of  individuals  must  pass  the  greater  part  of, 
their  lives  with  deposits  of  cheesy  matter  in  their 
bodies,  and  yet  not  become  the  subjects  of  general 
tuberculosis. 

Indeed,  the  great  frequency  of  caseous  matter  in  the 
tissues,  and  the  comparative  rarity  of  acute  tuberculo- 
sis, detracts  very  considerably  from  the  grave  significa- 
tion that  is  supposed  by  some  to  attach  to  the  presence 
of  such  matter  in  the  body. 

So  far  as  scrofula  itself  is  concerned  there  is  no  rela- 
tion between  the  severity  of  the  disease,  its  situation, 
the  extent  of  its  cheesy  products,  or  its  effect  on  the 
general  health,  and  the  liability  to  general  tuberculosis. 
This  disease  has  been  traced  to  caseous  glands,  to  scrof- 
ulous orchitis,  to  tubercular  disease  of  the  bladder,  to 
ulcers  of  mucous  membranes,  to  scrofulous  caries,  to 
inspissated  pus,  to  the  residues  of  other  than  strumous 
inflammations,  to  phthisis,  and  indeed  to  every  condi- 
tion that  may  involve  caseation.  Viewed  from  a  prac- 
tical point  of  view  I  do  not  imagine  that  the  prospect 
of  acute  miliary  tuberculosis  in  scrofula  can  effect  either 
in  one  way  or  in  another  any  mode  of  treatment  that 
may  be  proposed.  It  neither  makes  us,  on  the  one 
hand,  extremely  anxious  to  remove  at  once  from  the 
body  every  caseous  tissue  that  operation  can  remove ; 
nor  does  it  leave  us,  on  the  other,  absolutely  callous  as 
to  the  future  of  a  patient  who  retains  caseous  deposits 
in  his  body. 


64  THE  ETIOLOGY   OF  SCROFULA. 

CHAPTER  VIII. 

THE   ETIOLOGY   OF   SCROFULA. 

Scrofula  is  a  disease  that  may  be  both  hereditary  and 
acquired. 

With  regard,  in  the  first  place,  to  heredity,  a  tuber- 
cular parent  hands  down  to  the  offspring  that  particu- 
lar phase  of  tuberculosis  known  as  scrofula.  The  parent 
may  present  any  form  of  tuberculosis,  and  may  be 
scrofulous  or  phthisical,  or  the  subject  of  any  of  those 
diseases  commonly  classed  as  the  tubercular. 

It  is  only  when  such  transmission  occurs  that  scrofula 
can  be  strictly  regarded  as  an  hereditary  affection  ;  for 
by  heredity  in  disease  one  assumes  that  the  malady  in 
the  offspring  is  identical  with  that  in  the  parent,  or  is 
at  least  no  less  than  a  modification  of  it.  The  question 
as  to  the  probability  of  any  condition  of  ill-health  in  the 
parent,  other  than  that  due  to  tubercular  influence, 
causing  scrofula  in  the  progeny,  will  be  considered 
by-and-bye.  It  is  here  only  needful  to  remark  that  a 
vast  number  of  the  most  diverse  diseases  in  the  parents 
have  been  considered  as  active  in  that  direction. 

Phthisis  in  the  parents  is  an  extremely  common  cause 
of  scrofula,  in  children.  Lugol*  asserts  that  more  than 
one-half  of  all  scrofulous  patients  have  had.  phthisical 
progenitors.  Out  of  141  cases  of  scrofula  investigated 
by  Balman,  in  9  instances  the  father  had  died  of  phthi- 
sis, and  in  1 1  the  mother ;  while  among  the  near  or  dis- 
tant relations  of  these  scrofulous  patients  67  deaths 
from  phthisis  had  occurred  on  the  mother's  side,  and  89 
on  the  father's  side.  I  made  a  detailed  investigation 
into  the  family  history  of  65  scrofulous  patients — having 
especial  reference  to  this  matter  of  phthisis — with  the 
following  results.  In  27  of  these  cases  I  could  find  no 
trace  of  phthisis  among  any  members  of  the  patient's 
family  either  near  or  distant.  In  13  instances  the 
father    had    been   phthisical   and   in  6   instances   the 

*  "  Loc.  cit.,"  p.  46. 


THE   ETIOLOGY   OF   SCROFULA.  65 

mother.  In  the  remaining  19  cases  both  father  and 
mother  were  free  from  phthisis,  but  in  9  of  these 
instances  deaths  from  phthisis  had  occurred  among  the 
mother's  relations,  and  in  10  among  the  father's  rela- 
tions. The  patients,  whose  family  history  was  the  sub- 
ject of  this  inquiry,  presented  scrofulous  disease  under 
different  aspects,  but  the  majority  of  them  were  suffer- 
ing from  the  glandular  form  of  scrofula.  It  will  be 
seen  from  these  cases  that  phthisis  in  the  father  is  a 
potent  cause  of  scrofula.  In  several  instances  where 
this  condition  obtained  the  form  of  struma  was  markedly 
severe.  The  influence  of  this  ill-health  in  the  father  is 
often  very  conspicuous  in  cases  where  the  phthisis  has 
not  appeared  until  after  several  children  have  been 
born,  and  where  the  mother  is  healthy.  As  the  point 
is  important,  I  will  cite  two  cases  illustrative  of  this. 

A  woman,  aged  47,  had  13  children.  She  herself 
always  enjoyed  perfect  health,  was  vigorous  and  robust, 
and  there  was  no  suspicion  of  scrofula  or  phthisis  in 
any  branch  of  her  family.  Her  husband  died  at  the 
age  of  45  of  phthisis,  which  disease  had  first  shown 
itself  some  five  years  before  his  death.  Of  the  13 
children,  3  died  before  the  age  of  i^  years  from,  respec- 
tively, acute  bronchitis,  scarlet  fever,  and  convulsions. 
Four  of  the  children  were  born  during  the  last  six  years 
of  the  husband's  life,  and  these  are  all,  without  excep- 
tion, scrofulous.  The  remaining  6  children  have  per- 
fect health,  and  have  shown  no  traces  of  struma.  The 
family  were  in  good  circumstances,  and  the  mother 
could  in  no  way  account  for  the  delicate  health  of  her 
younger  children.  A  similar  case  was  kindly  commu- 
nicated to  me  by  Dr.  King  Kerr,  of  Leytonstone.  The 
father  died  at  the  age  of  37  of  phthisis,  having  been 
phthisical  for  three  years.  The  mother — who  was  of 
the  same  age  as  her  husband — was  a  perfectly  healthy 
woman.  Five  children  were  the  result  of  the  mar- 
riage. The  first  two  children  were  boys,  and  are  free 
from  any  trace  of  scrofula  ;  the  next  two  children  died 
in  infancy  of  simple  ailments ;  the  fifth  child  was  born 
two  months  before  the  father's  death,  i.  e.  the  father 
was  advanced  in  phthisis  when  the  mother  was  impreg- 
5 


66  THE   ETIOLOGY   OF   SCROFULA. 

nated.  This  infant,  at  two  months  old,  had  impetigo 
of  the  scalp,  followed  by  enlarged  glands  in  the  neck. 
When  ten  months  old  the  glands  in  the  neck  suppur- 
ated. Enlarged  glands  then  appeared  in  the  groin  and 
axillae,  abscesses  formed  in  many  parts,  the  mesenteric 
glands  became  affected,  and  the  child  died  at  the  age 
of  one  year  of  tubercular  meningitis. 

These  and  like  cases  appear  to  show  the  potency  of 
phthisis  in  the  father  as  a  cause  of  scrofula  ;  and  a  propos 
of  this  subject  it  may  be  observed  that  certain  writers 
have  pointed  out  that  in  all  cases  of  scrofula  the  health 
of  the  father  has  exercised  a  more  deleterious  effect  in 
the  causation  than  has  the  health  of  the  mother*  This 
statement  is,  however,  too  wide  and  general  to  permit 
of  its  being  accepted. 

Scrofula  in  the  parents  is  another  common  cause  of 
scrofula  in  children,  although  it  is  a  less  frequent  factor 
in  the  etiology  of  the  disease  than  is  phthisis.  It  is 
singular  also  that  in  the  majority  of  cases  the  scrofula  is 
in  the  mother,  f  At  least  such  is  the  result  of  my  own 
observations.  There  is  no  uniformity  in  the  disease 
transmitted.  The  mother  may  have  suffered  from  gland 
disease  and  the  child  may  have  a  strumous  joint,  or 
spinal  caries,  or  lupus  ;  or  the  parent  may  have  had  any 
of  these  affections,  and  the  child  have  glandular  lesions. 
It  is  interesting,  moreover,  to  note  how  interchangeable 
are  scrofulous  and  phthisical  influences.  Phthisis  in  one 
generation  may  appear  as  scrofula  in  the  next,  and  per- 
haps as  phthisis  again  in  the  third.  Atavism  is  observed 
in  the  transmission  of  these  diseases,  although,  I  believe, 
not  very  frequently.  I  have  notes  of  a  case  where  the 
grandmother  died  of  phthisis,  the  mother  had  sound 
health,  and  her  child  was  scrofulous.  Tyler  Smith:}:  in- 
sists on  the  possibility  of  one  generation  being  entirely 

*  See  for  example,  "  De  l'Adenopathie  cervicale  chez  les  Scrofuleux. 
These  de  Paris."     No.  469,  1879,  by  Dr.  L.   Deligny,  p    28.  _ 

+  Phillips  ("loc.  sit.,"  p.  119)  found,  on  examining  indiscriminately  a 
large  number  of  parents,  that  when  the  father  was  scrofulous  and  the 
mother  sound,  the  children  were  strumous  in  23  per  cent,  of  the  cases 
examined;  and  in  instances  where  the  mother  alone  was  scrofulous,  24 
per  cent,  of  the  offspring  showed  evidences  of  scrofulous  disease. 

\  "  Loc.  cit.,"  p  12. 


THE   ETIOLOGY   OF   SCROFULA.  6j 

missed  over  in  this  manner,  and  Hueter*  expresses  an 
identical  opinion. 

The  manner  in  which  the  disease  is  distributed  over 
the  members  of  a  family  in  cases  of  heredity  is  often 
incomprehensibly  irregular.  One  child  alone  may  be 
scrofulous  out  of  a  family  of  six  or  eight,  and  no  reason 
found  to  account  for  the  selection.  Some  of  the  chil- 
dren may  be  scrofulous,  some  phthisical,  and  the  rest 
simply  delicate.  Sometimes  the  younger  children  are 
more -scrofulous  than  the  elder;  or,  on  the  other  hand, 
the  elder  children  may  be  severely  affected,  and  the 
succeeding  progeny  but  slightly  influenced  by  the  dis- 
ease. And  these  inequalities  in  distribution  may  be 
independent  of  any  modification  in  the  health  or  circum- 
stances of  the  parents,  of  any  difference  in  diet,  of  any 
change  in  hygienic  surroundings,  and  appear  to  be  so 
far  really  unaccountable.  In  some  cases,  however, 
where  a  scrofulous  or  phthisical  taint  already  exists  the 
effects  of  mere  ill-health  in  the  parents  is  strikingly 
shown  in  the  children.  Dr.  Kennedyf  gives  a  good 
illustration  of  this.  A  peasant,  with  a  history  of  scro- 
fula in  some  members  of  his  family,  married  a  healthy 
woman.  Two  children  were  born,  who  remained  quite 
sound  and  well.  The  man  was  then  attacked  with 
rheumatic  fever,  and  subsequently  endured  great  pover- 
ty. During  this  period  of  depression  two  other  children 
were  born,  both  of  whom  became  scrofulous.  Finally, 
the  man  regained  his  health,  and  had  other  children, 
who  were  as  healthy  as  the  first.  (One  must  assume  in 
this  instance — an  assumption  all  would  not  allow — that 
the  scrofula  in  the  two  children  was  not  wholly  of  the 
acquired  variety.) 

I  would  therefore  quite  disagree  with  the  dogma  of 
Lugol,  who  says  that "  if  there  be  one  fact  in  pathology 
more  impossible  than  another,  it  is  that  one  child  should 
be  scrofulous  and  his  brothers  and  sisters  perfectly  free 
from  the  taint. "$ 

*  "Loc.  cit,,"  p.  264. 

f  "Natural  Selection  in  Scrofula."    Brit.  Med.  Joum.  vol.  i.    1874. 
p.  252. 

\  "  Loc.  cit.,"  p.  19. 


68  THE   ETIOLOGY   OF   SCROFULA. 

I  have  met  with  scrofulous  children  who  have  had 
brothers  and  sisters  in  whom,  I  think,  the  most  suspi- 
cious could  detect  no  evidence  of  any  "  scrofulous 
taint,"  unless  one  allows  the  term  scrofula  to  include 
the  enormous  area  now  occupied  by  the  simply  delicate 
and  the  non-robust.  Lugol  readily  disposes  of  all 
exceptions  to  his  rule  by  assuming  adulterous  inter- 
course on  the  part  of  the  mother. 

Now  comes  the  question — Can  conditions  of  ill-health 
in  the  parents  other  than  those  due  to  tubercular 
influence  cause  scrofula  in  the  children  ? 

Sir  J.  Clark  states,  a  propos  of  this  matter,  that  "  a 
deteriorated  state  of  health  in  the  parent,  from  any 
cause,  to  a  degree  sufficient  to  produce  a  state  of 
cachexia,  may  give  rise  to  the  scrofulous  constitution  in 
the  offspring."*  Many  subsequent  writers  have  endorsed 
this  statement,  but  I  am  inclined  to  think  that  it  has 
been  somewhat  too  widely  accepted.  A  fair  number  of 
cases  of  scrofula  are  met  with  in  patients  whose  parents 
show  neither  trace  of  scrofula  nor  tendency  to  phthisis, 
but  who  are  simply  in  a  "  deteriorated  state  of  health." 
A  detailed  examination  of  such  cases  gives  in  many 
instances  some  such  results  as  these :  either  the  parent 
had  some  manifestation  of  scrofula  in  youth,  all  traces 
of  which  have  since  disappeared,  or  there  is  a  history  of 
scrofula  or  of  phthisis  in  some  member  of  the  family, 
near  or  distant.  As  instances  of  this  latter  condition  I 
have  seen  scrofula  in  children  whose  parents  were 
apparently  healthy,  but  who  had  an  aunt  or  a  cousin 
the  subject  of  strumous  disease.  Had  one  or  other  of 
these  parents  been  in  a  cachectic  condition,  that 
cachexia  would  have  been  ascribed  as  the  sole  cause  of 
the  scrofula  in  the  children,  if  Sir  J.  Clark's  axiom  were 
upheld. 

In  one  case  that  I  examined,  the  father  and  mother 
were  both  free  from  actual  disease,  although  the  mother 
was  delicate,  and  there  was  no  history  of  scrofula  or 
phthisis  in  any  of  their  relations.  Their  youngest  child 
was,  however,  scrofulous.      Excluding  acquired  scrofula, 

*  "  A  Treatise  on  Pulmonary  Consumption,"  London,  1835,  p.  222. 


THE   ETIOLOGY   OF   SCROFULA.  69 

the  case  appeared  to  support  the  above  axiom,  until  in 
about  twelve  months'  time  the  mother  developed  pul- 
monary consumption. 

Still,  there  are  instances  where  such  explanations  do 
not  hold  good,  and  where  one  cannot  avoid  recognizing 
some  defects  in  the  parents'  health  other  than  those  due 
to  either  scrofula  or  tubercle.  I  do  not,  however,  think 
that  these  influences  are  common,  as  an  inquiry  into 
various  cachectic  conditions  will  show.  Cancer,  chronic 
lung  disease  (other  than  phthisis),  and  chronic  kidney 
disease,  may  produce  a  "  state  of  cachexia,"  and  they 
are  all  common  affections ;  yet  we  by  no  means  find 
that  scrofula  is  unduly  common  in  the  children  of  such 
individuals.  Observation  would,  indeed,  make  one  very 
loath  to  regard  these  diseases  as  causes  of  struma  in  an 
offspring.  Dr.  Grancher  applies  a  similar  observation 
to  "  the  whole  race  of  chlorotic,  dyspeptic,  and  cachectic 
persons,"  and  is  not  disposed  to  believe  that  they  can 
transmit  to  their  children  the  tendency  to  ill-health 
known  as  scrofula. 

I  think  it  is  to  syphilis  we  must  turn  for  an  example 
of  this  present  matter,  and  it  is  indeed  probably  the 
only  disease  other  than  tuberculosis  that  can  readily  or 
even  occasionally  produce  scrofula  in  the  offspring.  I 
have,  I  think,  undoubted  proof  in  several  instances 
that  syphilitic  parents  may  beget  strumous  children. 
One  or  two  of  such  instances  were  of  this  character : 
the  parents  had  been  syphilitic,  the  elder  children  had 
presented  syphilitic  symptoms,  such  as  interstitial  kera- 
titis or  stomatitis,  leading  to  deformed  teeth,  while  the 
younger  children  were  simply  scrofulous,  and  came 
with  eczema,  phlyctenular  ophthalmia,  enlarged 
glands,  &c.  In  less  modern  times  this  relationship 
between  scrofula  and  syphilis  was  considered  to  be 
very  close,  inasmuch  as  the  manifestations  of  hered- 
itary syphilis  were  included  under  the  head  of  scrof- 
ula. It  is  extremely  difficult  to  say  under  what  cir- 
cumstances transmission  of  the  disease  occurs ;  and 
even  those  who  strongly  maintain  the  connection  of 
the  two  disorders  do  not  venture  any  suggestions  upon 
this  point. 


•JO  THE   ETIOLOGY   OF   SCROFULA. 

Among  other  causes  reputed  to  produce  scrofula  in 
the  progeny  are  advanced  age  of  the  parents,  dispro- 
portion in  their  respective  ages,  and  especially  advanced 
years  in  the  father ;  marriage  of  near  kin ;  and  the 
usual  scapegoats  for  all  obscure  influences — intemper- 
ance and  sexual  excess.  It  must  be  confessed  that  the 
effect  of  these  supposed  causes  has  not  been  as  yet 
demonstrated. 

Among  the  general  predisposing  causes  of  scrofula 
may  be  mentioned — 

;.  Locality  and  Climate. — It  is  stated  that  scrofula 
is  much  more  common  in  some  regions  of  the  world 
than  in  others,  and  that  it  is  more  common  in  the  tem- 
perate zone  than  in  the  extreme  north  or  in  the  trop- 
ics. The  statements  of  authors  upon  this  head  are, 
however,  most  contradictory,  and  it  is  evident  that  a 
sufficient  number  of  well-authenticated  statistics  are 
not  at  present  forthcoming  on  which  to  establish  any 
conclusions  as  to  this  point.  Some  writers  have  gone 
to  great  extremes  upon  this  subject,  and  according  to 
Henning*  scrofula  is  nothing  but  a  climate  disease, 
and  is  due  to  certain  atmospheric  influences.  It  is 
possible,  however,  to  understand  that  scrofula  is  likely 
to  be  mo're  prevalent  in  cold  and  damp  districts  than 
in  warmer  and  drier  climates,  if  for  no  other  reason 
than  this — that  cold  and  damp,  and  the  greater  con- 
finement within  dwellings  necessitated  by  a  cold  cli- 
mate, would  be  apt  to  produce  those  catarrhs  that  are 
known  to  be  so  often  the  exciting  causes  of  scrofula. 
The  matter,  however,  does  not  rest  here,  for  the  habits 
of  the  various  races  must  be  considered,  as  well  as 
their  modes  of  living,  their  diet,  and  their  general  hygi- 
enic surroundings. 

2.  Certain  months  of  the  year  and  certain  seasons 
have  been  considered  to  effect  the  production  of  scrof- 
ula. Phillips  and  Lugol  assert  that  the  spring  is  the 
season  in  which  scrofula  most  commonly  makes  its 
appearance.     Tyler  Smith  cites  the  months  of  April, 

*  "  A  Critical  Inquiry  into  the  Pathology  of  Scrofula,"  by  S.  G.  Hen- 
ning,  M.D.,  1815,  p.  107. 


THE  ETIOLOGY   OF  SCROFULA.  7 1 

May,  October,  and  November  as  the  periods  most  con- 
cerned in  this  matter.  As  these  statements  refer 
mainly  to  the  production  of  glandular  disease,  they  are 
quite  intelligible  when  one  recollects  how  frequently 
gland  disease  depends  upon  a  mucous  catarrh,  and  how 
such  a  catarrh  acquired  in  the  winter  is  likely  to  lead 
to  a  scrofulous  manifestation  in  the  spring,  or  how  the 
asmospheric  conditions  of  spring  itself  may  not  be  inac- 
tive in  this  direction.  Probably,  therefore,  these  state- 
ments, so  far  as  they  refer  to  gland  disease,  are  to  some 
extent  correct. 

3.  Age. — Scrofula  is  essentially  a  disease  of  early  life. 
The  marked  implication  of  the  absorbent  system  in 
scrofula,  on  the  one  hand,  and  the  great  activity  of 
that  system  in  early  life,  on  the  other,  are  well-nigh 
sufficient  to  explain  this  fact.  The  glands  in  young 
children  are  comparatively  larger  than  in  adults,  while 
the  more  conspicuous  masses  of  adenoid  tissue  in  the 
body,  such  as  the  tonsils,  Peyer's  patches,  and  the  soli- 
tary glands  are  also  unduly  prominent.  In  perfectly 
healthy  children,  under  the  age  of  three,  and  who  are 
not  too  stout,  I  have  often  been  able  to  feel  glands  in 
the  posterior  triangle  of  the  neck  that  are  not  obvious 
to  the  touch  in  even  very  thin  adults.  As  age 
advances,  the  absorbent  system  becomes  less  active, 
and  in  the  old  the  glands  are  often  shriveled  and  hard, 
and  much  smaller  than  are  those  met  with  in  the  prime 
of  life. 

As  we  have  seen  how  constantly  the  lymphatic  tis- 
sues are  implicated  in  scrofula,  it  will  follow  that  these 
facts  explain  not  only  the  undue  frequency  of  glandu- 
lar disease  in  the  young,  bnt  the  occurrence  also  of 
bone  and  joint  affections,  of  ulcers,  of  cold  abscess,  and 
other  strumous  manifestations.  There  is  a  fair  amount 
of  uniformity  among  authors  as  to  the  commonest  time 
of  life  for  the  appearance  of  scrofula.  Thus  Lombard 
gives  from  four  to  eight  years  old.  Balman's  statistics 
show  that  73.76  per  cent,  of  the  cases  of  gland  scrofula 
occurred  between  the  ages  of  two  to  fifteen  years. 
Tyler  Smith  asserts  that  two-thirds  of  all  gland  cases 
occur  before  twelve  years  of  age.      Hueter  gives  the 


72  THE    ETIOLOGY   OF   SCROFULA. 

commonest  periods  for  the  commencement  of  scrofula 
as  between  three  and  twelve  years,  and  Birch-Hirsch- 
feld  as  between  three  and  fifteen. 

From  an  analysis  of  509  cases  in  the  records  of  the 
Margate  Infirmary,  I  find  that  the  largest  number  of 
scrofulous  disorders  of  all  kinds  have  made  their  first 
appearance  between  the  ages  of  five  and  fourteen. 
The  superficial  affections  of  the  skin  and  mucous  mem- 
brades  are  not  included  in  these  statistics.  They 
undoubtedly  occur  at  a  still  earlier  period,  and  are 
among  the  very  first  manifestations  of  scrofula.  Owing, 
moreover,  to  restrictions  as  to  age  at  the  Infirmary, 
these  statistics  do  not  include  all  those  who  may  have 
died  or  may  have  been  cured  before  the  age  of  six ; 
and,  allowing  this,  it  is  probable  that  the  ages  given  by 
Birch-Hirschfeld  of  three  to  fifteen  are  more  correct 
than  those  resulting  from  these  records. 

An  analysis  of  the  Margate  cases  in  this  matter  of 
age  will  be  found  on  the  next  page. 

Another  period  when  scrofula  not  unfrequently 
appears,  is  between  20  and  30,  and  then  a  little  after 
30.  Rindfieisch  mentions  the  former  period  as  one 
common  for  the  development  of  hereditary  scrofula. 
So  far  as  my  own  experience  goes,  snch  disease  is  more 
common  in  females,  and  is  apt  to  present  itself  in  the 
glandular  apparatus.  In  three  cases  of  adult  scrofula 
reported  in  the  "  Transactions "  of  the  Pathological 
Society,  and  already  referred  to,  the  ages  of  the 
patients  were  respectively  45,  33,  and  30,  when  the 
disease  commenced.  They  were  all  females,  and  the 
disease  in  each  case  glandular.  Other  cases  will  be 
alluded  to  on  the  chapter  on  Gland  Affections.  Lastly, 
scrofula  may  appear — perhaps  for  the  first  time — 
in  old  age.  Sir  James  Paget*  was  the  first  to  fully 
describe  this  condition  under  the  title  of  "  senile  scofu- 
la,"  and  the  subject  has  since  been  very  exhaustively 
treated  by  Dr.  Bourdelais.f     The  matter  will  be  alluded 

*  "  Clinical  Lectures  and  Essays."     London,  1875. 

f  "  Sur  quelques  Observations  de  Scrofule  chez  le  Vieillard.  These 
de  Paris,"  No.  297,  1876.  See  also  "  Considerations  sur  quelques  Affec- 
tions scrofuleuses  chez  le  Vieillard,"  by  Dr.  Dumoulin.     Paris,  1854. 


THE   ETIOLOGY   OF  SCROFULA. 


73 


TABLE 

Gland  Disease.       Males.        Total  66. 


Ages  at  which  the 
disease  commenced 

J"4 

5-9 

10-14 

15-19 

20-24 

25-29 

30-34 

35-39 

40-44 

45-49 

Not 
known 

Number  of 

) 

patients  in  each 
division  of  age 

>■  I0|    21 
)        1 

14 

6 

1 

3 

1 

1 

9 

Gland  Disease. 

Females. 

Total  89. 

Number  of 

) 

patients  in  each 
division  of  age 

I8 

22 

34 

9 

5 

2 

1 

2 

1 

5 

Bone  Disease. 

Males. 

Total  75'. 

Number  of 

I  i     18 

patients  in  each 

18 

10 

8 

7 

1   1  — 

2 

— 

10 

division  of  age 

S   1 

1 

Bone  Disease. 

Females. 

Total  77. 

Number  of 

) 

1 

patients  in  each 

t 8 

20 

23 

9 

7 

— 

1        1 

1 

— 

7 

division  of  age 

i 

yoint  Disease. 

Males. 

Total  86. 

Number  of      1  ) 
patients  in  each    >  6 

1         1 

28 

18 

13 

5 

4 

1 

— 

—        1      10 

division  of  age  |  ) 

1 

yoint  Disease. 

Females 

Total  57. 

Number  of      1  ) 

1 

patients  in  each    >  6 

8 

22 

II         I 

1 

1 

3 

— 

1 

3 

division  of  age  ]  ) 

1 

to  subsequently.  In  the  16  cases  reported  by  Dr. 
Bourdelais,  the  ages  of  the  patients  are  as  follow :  one 
patient  was  41  years  of  age,  and  another  57  ;  five  were 
between  60  and  70  ;  seven  were  between  70  and  80 ;  and 
two  were  more  than  80  years  old. 

Scrofula  is  comparatively  uncommon  before  the  age 
of  one  year.  Such  cases  as  I  have  seen  under  that  age 
have  mostly  been  severe,  and  have  in  every  instance 
been  associated  with  distinct  heredity.  Most  of  the 
cases  of  "  infantile  struma "  described  by  the  older 
authors  are  evidently  cases  of  hereditary  syphilis. 

4.  Sex. — With  regard  to  sex,  I  believe  no  distinctions 
are  observed  in  scrofula.  It  is  equally  common  both  in 
male  and  female.  Reliable  statistics  on  this  head  are 
almost  impossible  to  obtain,  owing  to  the  fact  that  while 


74  THE  ETIOLOGY   OF   SCROFULA. 

severe  cases  of  the  disease  come  under  hospital  or  dispen- 
sary treatment,  the  milder  cases,  the  majority,  are  met 
with  in  comparatively  small  numbers.  The  509  Margate 
cases  are  thus  distributed  : — 

Males.         Females. 
Gland  disease        .       ...     66  89 

Bone  disease 75  77 

Joint  disease 86  $7 

Other  cases 21  38 


Total     ....  248  261 

These  figures,  however,  cannot  be  regarded  as  of  much 
value,  beyond  showing,  perhaps,  that  gland  disease 
appears  to  be  more  common  in  the  female,  and  that 
joint  affections  are  more  common  in  the  male,  due  possi- 
bly to  the  greater  liability  to  injury  in  that  sex.  The 
researches  of  Dr.  Bourdelais  show  that  senile  struma  is 
more  common  in  the  female,  and  I  think  that  that 
remark  may  apply  to  most  cases  of  adult  scrofula. 

5.  Complexion. — There  appears  to  be  no  possible  con- 
nection between  scrofula  and  any  particular  complexion. 
At  one  time  it  was  stated  that  scrofula  occurred  in  the 
fair-haired,  and  a  mass  of  figures  was  brought  forward  to 
substantiate  this  fact.  It  was  then  discovered  that  it 
was  more  common  in  the  dark-complexioned,  and  an 
equally  large  mass  of  figures  supported  that  observation 
also.  Conclusions  on  this  point  are  absolutely  valueless, 
unless  the  observer  can  give,  at  the  same  time,  the  gene- 
ral proportions  of  fair-and  dark-complexioned  persons 
in  the  particular  country  or  locality  in  which  his  inves- 
tigations on  scrofula  have  taken  place.  In  the  cases  I 
obtained  from  the  Margate  records,  details  as  to  com- 
plexion, color  of  hair  and  eyes,  &c,  are  given  in  450 
cases.  Of  this  number  221  were  air,  115  I  classed  as 
"  medium,"  and  1 14  as  dark.  From  these  statistics  one 
can  only  conclude  that  in  England,"  or  at  least  in  that 
class  of  society  from  whom  these  scrofulous  patients  are 
drawn,  the  fair-complexioned  are  in  the  majority. 
Phillips'  s  investigations  show  only  32  per  cent,  as 
presenting  light  hair  and  eyes.     In  49  cases  at  l'Hopital 


THE   ETIOLOGY   OF   SCROFULA.  75 

de  Berck,  recorded  by  Dr.  Deligny,*  3  had  brown  hair, 
28  a  deep  chestnut,  1 1  light  chestnut,  and  7  blonde. 

Acquired  Scrofula. — Although  I  would  strongly  urge 
that  in  the  great  majority  of  all  scrofulous  cases  a  tend- 
ency that  favors  the  particular  process  of  scrofula  has 
been  inherited  from  the  parents,  it  must  be  owned  that 
in  some  instances  the  disease  may  be  independent  of  such 
heredity,  and  be  developed  de  novo.  I  believe  cases  of 
pure  acquired  scrofnla  to  be  uncommon,  and  certainly 
less  frequent  than  in  former  days.  The  circumstances 
under  which  scrofula  may  be  acquired  are  very  numer- 
ous, and  for  the  most  part  imply  simply  such  influences 
as  would  lead  to  general  bad  health.  As  the  most  impor- 
tant, may  be  mentioned — bad  ventilation  and  overcrowd- 
ing ;  absence  of  sunlight  ;  insufficient,  bad,  or  unsuit- 
able food ;  cold  and  damp  ;  imperfect  clothing ;  and, 
indeed,  all  those  conditions  that  are  the  common  sur- 
roundings of  squalor  and  poverty.  To  scrofula  developed 
under  many  of  these  circumstances,  one  might  well  apply 
the  term  of  Grancher,  "  la  scrofule  a  miseria."  It  may 
thus  be  said,  therefore,  that  acquired  struma  is  practi- 
cally limited  to  the  poor;  and  continuing  the  same  argu- 
ment, it  may  reasonably  be  assumed  that  the  great 
majority  of  cases  of  scrofula  among  the  rich  are  due  to 
heredity.  Upon  this  latter  point  M.  Chauffard  and 
others  have  especially  insisted.f  I  think  general  expe- 
rience will,  however,  allow  that  scrofula — especially  its 
severer  forms — is  much  less  common  among  the  rich 
than  among  the  poor.  Apart  from  the  many  advantages 
of  the  wealthy,  the  poor,  while  most  prone  to  develop 
acquired  forms  of  struma,  are  not  exempt  from  the  here- 
ditary phases  of  the  disease.  As  many  of  the  conditions 
just  referred  to  as  inducive  of  scrofula  are  more  apt  to 
be  met  with  in  crowded  habitations,  it  happens  that 
scrofula  is  somewhat  more  frequent  in  large  towns  than 
in  the  open  country.  The  disproportion  would  appear, 
however,  to  be  slight,  for  although  the  child  of  a  farm 

*  "  Loc.  cit.,"  p.  25. 

f  M.  Chauffard.  "  Premiere  livraison  du  Correspondant,"  July  1870, 
p.  172.  See  also  MM.  Perrochaud  and  Cazin,  "  Soc.  de  Chir. ,"  April 
1876. 


y6  THE   ETIOLOGY   OF   SCROFULA. 

laborer  may  have  plenty  of  air  and  light  in  the  daytime, 
it  is  as  likely  to  be  improperly  and  imperfectly  fed  as  is 
the  town  child,  and  probably  occupies  an  apartment  at 
night  that  in  the  matter  of  foul  air  and  filth  could  not 
be  well  beaten  in  the  purlieus  of  the  dirtiest  city.  As 
examples  of  acquired  scrofuia  I  may  cite  the  follow- 
ing :— 

A  girl,  aged  16,  had  extensive  gland  enlargements  on 
both  sides  of  the  neck.  These  had  been  noticed  8 
months.  The  patient  was  the  fifth  child  out  of  a  family 
of  eleven.  Her  father  and  mother  were  healthy.  There 
was  no  trace  of  phthisis  or.scrofula  in  any  branch  of  the 
family,  nor  in  any  of  the  other  children.  Five  of  the 
eleven  had  died  in  infancy  of  simple  ailments.  These 
were  respectively  the  first,  fourth,  seventh,  ninth,  and 
eleventh  children.  For  the  last  18  months  the  patient 
had  worked  in  a  small  close  room,  had  had  little  or  no 
outdoor  exercise,  and  been  very  indifferently  fed.  Previ- 
ous to  this  time  the  family  had  for  some  months  expe- 
rienced severe  poverty.  As  compared  with  the  rest  of 
the  family  the  child  had  always  somewhat  been  delicate. 
To  take  a  case  later  in  life.  A  female,  aged  20,  had 
greatly  enlarged  glands  in  the  neck,  which  had  existed 
for  14  months,  and  had  suppurated.  Her  parents  were 
healthy.  There  was  no  phthisis  in  any  of  the  family, 
and  all  her  brothers  and  sisters  were  free  from  any  trace 
of  scrofula.  Some  year  or  so  before  the  gland  disease 
appeared,  she  began  a  very  sedentary  employment,  and 
worked  in  a  close,  ill-ventilated  room.  As  she  endea- 
vored at  the  same  time  to  support  herself,  her  food  was 
poor  and  insufficient. 

The  best  examples,  however,  of  acquired  scrofula 
have  been  furnished  by  poor-houses  and  prisons.  The 
facts  from  these  sources  are  very  clear.  Patients  who 
have  always  enjoyed  good  health,  who  have  no  trace  of 
tubercular  mischief  in  any  member  of  their  family, 
enter  one  of  these  of  institutions.  Close  confinement, 
want  of  exercise,  poor  and  insufficient  food,  and  perhaps 
'plenty  of  work,  soon  take  effect,  and  many  under  these 
conditions  develop  distinct  scrofulous  disease. 

It  must  be  said,  however,  that  examples  of  scrofula 


THE   ETIOLOGY   OF   SCROFULA.  JJ 

from  these  sources  are  much  rarer  now  than  they  were 
formerly,  owing  to  the  greatly  improved  hygienic  con- 
ditions of  workhouse  inmates  and  prisoners  at  the 
present  time.  As  an  instance  of  "  parochial  struma," 
I  might  quote  this  observation  from  Tyler  Smith's 
book.*  In  a  worknouse  in  Kent  there  were  on  April 
29,  1 841,  78  boys  and  94  girls.  It  is  stated  that  all  these 
children  were  healthy  when  admitted  and  free  from 
scrofula.  When  examined  enlarged  glands  were  found 
in  all  the  boys  and  in  91  of  the  girls.  The  following 
was  the  diet  these  children  enjoyed — bread  and  cheese 
for  dinner  four  days  in  the  week,  suet  puddings  and  veg- 
etables on  two  days,  and  meat  (in  small  quantity)  on  the 
remaining  day  of  the  seven.  One  of  the  best  accounts 
of  what  Autenrieth  \  calls  "  penitentiary  scrofula,"  is 
given  by  Dr.  Deligny  in  his  statistics  of  the  disease  in 
certain  French  prisons.  He  gives  a  vast  number  of 
instances  of  prisoners  from  25  to  40  years  of  age  or 
older,  who  entered  the  prison  without  a  trace  of  struma, 
and  yet  developed  gland  tumors  that  suppurated  before 
a  long  period  of  confinement  had  passed.  Indeed,  in 
six  instances,  scrofula  appeared  within  eight  months  of 
admission.  His  statistics  extend  from  the  year  1861  to 
1872,  and  he  ascribes  the  occurrence  of  the  disease  to 
bad  air,  want  of  exercise,  and  poor  and  insufficient  food. 
On  remedying  these  evils  the  patients  at  once  improved. 
Dr.  Grancher;};  remarks  that  after  the  siege  of  Paris  he 
met  with  many  persons  who  had  become  anaemic,  and 
had  developed  gland  tumors.  They  recovered,  but  in 
many  cases  the  masses  suppurated,  and  some  became 
caseous. 

The  actual  exciting  causes  of  scrofula  are  very  numer- 
ous. A  tendency  to  scrofulous  inflammation  being 
inherited  or  acquired,  it  needs  but  a  slight  exciting 
cause  to  produce  an  outburst  of  the  disease.  Many  of 
these  exciting  causes  will  be  referred  to  more  in  detail 
when  treating  of   gland  disease.     Speaking  generally, 

*  "loc  cit. ,"  p.  39. 

\  "Spec.  Nosologie  und  Therapie."  Wurzburg,  1836,  ii.  p,  333 

%  "Loc.  cit,,  Diet.  Encyclop.,"  p.  343. 


78  THE   ETIOLOGY   OF   SCROFULA. 

one  might  say  say  that  any  condition  that  impairs  the 
health  the  health  of  a  person  predisposed  to  scrofula  is 
sufficient  to  bring  about  some  manifestation  of  the 
malady.  Thus  scrofula  often  appears  for  the  first  time 
after  the  eruptive  fevers.  Measles  appears  to  be  very 
commonly  an  arouser  of  the  scrofulous  process.  It  acts, 
like  scarlet  fever,  not  only  by  temporarily  impairing  the 
health,  but  also  through  the  catarrh  that  is  a  symptom 
of  both  diseases.  Scrofulous  manifestations  have  some- 
times appeared  for  the  first  time  after  vaccination. 
This  might  be  merely  a  coincidence,  or  might  be  due 
to  the  slight  impairment  of  health,  associated  with  vac- 
cination, acting  upon  a  subject  already  predisposed  to 
struma.  Richard  Carmichael*  considered  digestive  dis- 
orders as  the  usual  exciting  cause  of  scrofula,  and  others 
have  endorsed  this  view.  The  statement,  I  believe  to 
be  fallacious,  except  perhaps  in  a  very  few  instances. 
The  digestive  disorders  of  such  patients  are,  as  a  rule, 
actually  due  to  a  scrofulous  affection  of  the  mucous 
membranes,  and  the  disease  therefore  is  already  exist- 
ing, however  caused.  In  some  cases  scrofula  has 
appeared  for  the  first  time  during  pregnancy  or  lacta- 
tion, and  in  cases  where  the  disease  has  existed  in  child- 
hood these  conditions  often  cause  it  to  reappear. 

In  concluding  the  subject  of  etiology  I  must  express 
a  belief  that  scrofula  is  on  the  decrease,  and  that  the 
manifestations  of  the  disease  are,  on  the  whole,  not  so 
severe  as  they  were  in  former  days.  I  am  aware  that 
many  of  the  older  authors  described  as  scrofulous  cases 
which  we  now  know  to  be  syphilitic,  or  even  cancerous, 
or  at  least  due  to  a  disease  other  than  that  with  which 
we  are  now  concerned.  But  making  all  allowance  for 
this,  the  account  in  the  past  of  the  prevalence  of  scrof- 
ula could  not  apply  to  the  present  time,  We  read  of 
workhouses,  schools,  and  penitentiaries  in  the  early  part 
of  this  century  the  inmates  of  which  were,  nearly  all 
scrofulous.  We  read  of  scrofula  as  a  wide-spread, 
severe,  and  distressing  disease  among  the  inhabitants 
of  little  towns  and  villages  where  now  it  is  but  little 

*  "  On  the  Nature  of  Scrofula,"  1810,  p.  20 


THE   SCROFULOUS   INDIVIDUAL.  79 

seen.*  We  hear  of  immense  gland  enlargements  lead- 
ing to  suppuration  and  death  as  of  no  uncommon  occur- 
rence ;  and  making  every  allowance  for  errors  in  diag- 
nosis and  a  reckless  use  of  the  word  scrofula,  the  mor- 
tality from  the  disease  is  certainly  much  less  than  it 
was  years  ago.  Common  as  scrofula  was  in  Carmichael's 
days,  he  speaks  of  it  as  "more  common  years  ago  ;  "f 
and  Phillips,  who  was  greatly  impressed  with  the 
amount  of  struma  in  England  in  1846,  concludes  that 
"  scrofula  is  much  less  prevalent  at  the  present  day  than 
it  was  in  the  seventeenth  and  eighteenth  centuries."  ^ 
And  coming  more  to  detail,  Mr.  Vernon,  §  speaking  of 
strumous  eye  affections,  maintains  that  we  rarely  meet 
nowadays  .with  such  severe  cases  as  were  common  in 
times  gone  by. 

The  dimunution  of  scrofulous  diseases  is  easily  to  be 
explained  by  the  vast  improvements  that  have  been 
made  of  late  in  sanitary  science,  by  the  better  condition 
of  the  poor  as  regards  all  matters  of  health,  and  by 
advances  possibly  in  the  science  of  medicine  and  in  the 
treatment  of  disease. 


CHAPTER  IX. 

THE    SCROFULOUS    INDIVIDUAL. 

The  physiognomy  of  scrofula,  the  type  of  face  and 
form  supposed  to  be  indicative  of  the  disease,  have  for 
ages  been  subjects  upon  which  writers  have  loved  to 
exercise  their  imaginative  and  descriptive,  powers. 
Some  extraordinary  pictures  have  been  given  of  the 
scrofulous  individual,  who  has  at  one  time  appeared 
repulsive  and  at  another  peculiarly  pretty.  Some  of  the 

*  See  Hamilton's  observations,  for  example,  on  the  amount  of  scrofula 
in  the  town  of  Lynn  in  1781,  loc   cit.,  p.  160. 
+    "  Loc.  cit.,"  p.  54. 
I  "  Loc.  cit.,"  p.  98. 
§  "Scrofulous  Iritis,"  British  Med.  Journ.%  vol.  ii,  1874,  p.  276. 


80  THE   SCROFULOUS   INDIVIDUAL. 

older  writers  describe  the  physiognomy  of  the  strumous 
with  such  precision  that  had  their  statements  been  even 
partially  true,  all  sufferers  from  that  disease  could  have 
been  recognised  at  a  glance.  Other  observers  divided 
the  scrofulous  into  two  classes — the  sanguine  and  the 
melancholic,  each  with  well-marked  and  distinctive  fea- 
tures and  appearance.  This  division,  while  ingenious 
and  affording  great  opportunities  for  the  exercise  of 
fancy,  had  the  practical  disadvantage  that  the  bulk  of 
scrofulous  persons  belonged  neither  to  the  one  class  nor 
to  the  other.  Writers  in  later  times  have  possibly  gone 
to  the  other  extreme,  and  have  asserted  that  there  is  no 
type  of  countenance  or  figure  that  is  peculiar  to  the 
strumous,  or  that  is  even  of  common  occurrence  among 
them.  Others,  again,  like  Bazin,*  have  so  generously 
described  "  the  scrofulous  habit,"  that  it  might  include 
every  individual  who  was  not  conspicuously  robust. 

Many  of  these  discrepancies  depend  upon  incorrect 
ideas  of  the  clinical  characters  of  scrofula,  and  upon  the 
forced  attempt  of  the  older  pathologists  to  associate 
every  disorder  with  some  distinctive  physiognomy. 
Several  of  the  older  descriptions  of  the  scrofulous  face 
or  habit  are  compounded  from  the  features  of  phthisis, 
rickets,  and  hereditary  syphilis, ;  while  not  a  few  simply 
coincide  with  the  outward  manifestations  of  one  or  other 
of  these  diseases.f  Bredow  had  never  seen  a  hare-lip 
but  in  a  scrofulous  child,  and  Macartney  discovered 
certain  mental  features  in  the  scrofulous  "  which  more 
strikinkly  indicate  the  peculiar  state  of  the  constitution 
than  do  all  the  other  signs."  Moreover,  many  of  the 
characteristics  of  the  strumous  physiognomy,  as  descri- 
bed by  some,  belong  in  reality  to  the  already  developed 
disease,  and  among  such  features  may  be  mentioned  the 
swollen  and  thick  neck,  the  enlarged  upper  lip,  the  sore 
eyes,  the  tumid  eyelids.  Omitting  further  discussion  as 
to  opinions  that  have  been  held,  and  reviewing  the  mat- 


*  "  Lecons  theoriques  et  cliniques  sur  la  Scrofule,"  2nd  ed.  1861. 
Paris. 

f  See,  for  example,  "The  Pathology  and  Treatment  of  Scrofula,"  by 
Robert  Glover,  M.  D.,  1846,  p.  145. 


THE   SCROFULOUS   INDIVIDUAL.  8l 

ter  from  the  clinical  and  pathological  bases  I  have 
already  given,  it  may,  I  think,  be  said  that  there  is  no 
physiognomy  quite  distinctive  of  scrofula,  no  type  of 
face  or  form  so  peculiar  to  the  disease,  or  of  so  common 
occurrenc  among  its  victims,  that  it  is  possible  to  recog- 
nise in  all  cases  the  "  scrofulous  habit  "  considered  apart 
from  actual  manifestations  of  struma.  Scrofula  may 
occur  in  persons  of  perfectly  healthy  aspect.  I  can  call 
to  mind  a  little  lad  some  ten  years  of  age  who  came  to 
me  with  gland  masses  in  the  neck,  and  whose  rosy  and 
chubby  cheeks  and  general  bearing  of  robust  health 
singled  him  out  from  among  a  number  of  less  vigorous 
out-patients.  Speaking  generally,  the  physiognomy  of 
of  scrofula  is  the  physiognomy  of  poor  health.  The 
most  that  can  be  said  of  the  aspect  of  many  strumous 
patients  is  simply  that  they  do  not  look  well,  that  they 
are  delicate  in  appearance.  Our  scanty  knowledge  of 
the  factors  of  simple  frailty  of  health  scarcely  enables 
us  to  say  more  than  this  of  many  strumous  paients. 
Put  a  number  of  such  scrofulous  children  together,  and 
one  can  merely  say  that  they  look  out  of  health.  There 
is  perhaps  no  conformation  of  face,  no  particular  features, 
common  to  even  the  majority  of  them.  When  these 
children  present  glandular  swellings  or  chronic  joint 
diseases  or  certain  bone  affections,  it  is  then  easy  enough 
to  say  that  they  are  scrofulous  ;  but  looking  at  them 
without  any  known  manifestations  of  scrofula  at  all,  who 
will  be  bold  enough  to  call  even  a  few  of  them  "  scrofu- 
lous," or  distinguish  them  from  a  mass  of  children  that 
can  be  seen  crawling  about  the  slums  of  a  great  city, 
and  that  merit  no  higher  scientific  term  than  that  of 
being  "  seedy-looking  "  ? 

Excluding  scrofulous  individuals  that  on  the  one  hand, 
look  robust,  and  on  the  other,  merely  out  of  health,  we 
at  last  arrive  at  a  class  of  the  strumous  who  present 
something  approaching  distinctiveness  in  their  physiog- 
nomies. 

The  general  features  of  this  class  are  sufficiently  well 

marked  to  enable  us  to  separate  them  into  two  divisions, 

that,  for  the  want  of  better  words,  may  be  known  by  the 

old   terms — the  sanguine  *and  the  phlegmatic  types  of 

6 


82  THE   SCROFULOUS   INDIVIDUAL. 

scrofula.  It  would,  I  think,  be  well  to  speak  of  these  as 
types  rather  of  defective  health  than  as  types  of  that 
special  form  of  ill-health  known  as  scrofula  ;  for  while 
persons  showing  the  features  of  one  or  other  of  these 
classes  are  for  the  most  part  scrofulous,  the  whole  are 
not.  And  these  exceptions — very  few  although  they  may 
be — render  it  impossible  for  us  to  say  that  every  indivi- 
dual presenting  the  characters  of  one  or  other  of  these 
typical  classes  must  be  scrofulous.  If  but  a  few  non- 
syphilitic  children  were  found  with  "  Hutchinson's 
teeth,"  depressed  noses,  and  prominent  brows,  the  physi- 
ognomy of  hereditary  syphilis,  would  cease  to  be  typical, 
and  would  occupy  the  position  with  regard  to  syphilis 
that  I  believe  the  "  sanguine  "  and  "  phlegmatic  "  types 
of  scrofula  occupy  to  that  disease. 

It  will  now  be  convenient  to  describe  these  types  of 
unhealthy  person  that  are  so  frequently  met  with  among 
the  strumous. 

i.  The  sanguine  type.  Individuals  placed  in  this  class 
are  credited  with  these  features,  and  they  refer  more 
particularly  to  children.  They  are  tall,  slight,  and  grace- 
ful, with  well-formed  limbs,  hands,  and  feet,  a  fine  clear 
skin,  and  usually  a  fair  complexion.  The  face  is  oval, 
the  lower  jaw  small,  the  features  delicate  and  regular, 
the  lips  thin.  The  eyes  are  bright,  and  covered  with 
long  lashes,  and  the  hair  is  often  remarkably  fine  and 
silken,  A  sprightly  and  excitable  disposition  may  be 
added,  and  the  picture  is  complete.  These  features  are 
identical  with  those  described  by  Sir  W.  Jenner*  as 
typical  of  the  tubercular  child,  and  they  also  very  fairly 
accord  with  the  usual  type  of  the  phthisical  indivi- 
dual.f 

The  leading  points  of  this  physiognomy  were  admir- 
ably shown  in  a  series  of  photographs  exhibited  in  the 
Museum  of  the  International  Medical  Congress  by  Dr. 
Mahomed  and  Mr,  Galton4     By  some  special  process  a 

*  Article  on  "Tuberculosis,"  Med.  Times  and  Gaz.,  vol.  ii.  1863,  p. 
423.  See  also  Art.  by  Dr.  Laycock,  on  "The  Physiognomical  Diagnosis 
of  Disease,"  Med    Times  and  Gaz.,  vol.  i.  1862,  p.   341 

f  See  description  by  Ruehle,  "loc.  cit.,"  p.  510. 

\  Some  details  are  given  in  the  "  Museum  Catalogue, "  1881,  p.  81. 
Also  in  "  Abstracts,"  p.  152, 


THE   SCROFULOUS  INDIVIDUAL.  83 

"  composite  "  photograph  is  produced  of  many  indivi- 
duals. In  this  composite  picture — a  single  face — "  all 
that  is  common  remains,  all  that  is  individual  disap- 
pears." The  typical  or  average  face  thus  produced 
from  a  number  of  phthisical  women  agrees  with  the 
description  above  given,  and  is  a  face,  it  must  be  owned, 
that  is  singularly  graceful  and  delicate.  Some  physi- 
cians have  described  a  "  catarrhal  diathesis,"  a  tendency 
to  frequent  inflammation  of  mucous  membranes ;  and 
the  features  ascribed  to  persons  with  such  a  diathesis 
accord  also  with  this  so-called  sanguine  form  of  scrofu- 
la.* It  is  obvious  that  under  various  terms  and  in 
connection  with  various  diseases,  the  same  type  of  un- 
healthy individual  has  been  described.  Lastly,  the  name 
of  serous  or  erethic  scrofula  has  been  given  by  this  type. 
2.  In  the  phlegmatic  type  are  comprised  individuals 
as  a  rule  short  and  burly,  with  coarse  limbs,  large  hands 
and  feet.  The  face  is  broad,  the  lower  jaw  large,  the 
malar  bones  often  prominent,  the  features  coarse  and 
irregular.  The  nose  is  generally  thick,  the  lips  tumid, 
the  lobes  of  the  ears  large,  and  the  neck  unshapely. 
The  skin  is  coarse,  harsh,  and  thick.  The  amount  of 
subcutaneous  cellular  tissue  is  considerable,  and  often 
sufficient  to  conceal  the  muscular  outlines  of  the  body. 
The  skin  in  the  previous  type  is  fine,  and  it  is  possi- 
ble to  pinch  up  with  the  fingers  a  little  portion  of  it ; 
but  in  these  individuals  none  but  a  large  fold  of  skin 
can  be  picked  up,  as  it  is  so  coarse.  Speaking  generally, 
persons  of  this  class  appear  flabby  and  heavy-looking  ; 
they  are  apathetic,  have  little  muscular  power,  and  are 
soon  tired.  The  vascularity  of  their  tissues  appears  to 
be  impaired,  and  leads  to  certain  peculiarities  of  parts 
that  will  be  dealt  with  subsequently.  This  type  is  very 
well  represented  in  the  photographic  series  of  Dr. 
Mahomed  and  Mr.  Galton,  under  the  title  of  "  coarse 
struma,"  the  examples  being  all  obtained  from  phthis- 
ical patients.  Older  authors  described  a  like  individual 
under   the    name    of   melancholic   scrofula,  and  many 

*  "  De  la  Diathese  catarrhale   ck*s  jeunes    Filles,"   by   Dr.   Richelot. 
"  L'Union  Medicale,"  March  3,  1881,  p.  367. 


84  THE   SCROFULOUS   INDIVIDUAL. 

accounts  of  what  is  known  as  the  lymphatic  tempera- 
ment accord  with  the  above. 

It  must  be  distinctly  understood  that  these  descrip- 
tions are  merely  typical.  Many  scrofulous  individuals 
— as  before  stated — can  perhaps  not  be  placed  with 
certainty  either  in  the  one  division  or  in  the  other. 
Moreover,  out  of  the  whole  mass  of  the  strumous  there 
may  be  comparatively  few  who  would  present  all  the 
features  of  one  or  other  of  these  types ;  and  those  who 
expect  to  find  commonly  among  the  scrofulous  physi- 
ognomies so  marked  as  those  above  detailed  will  cer- 
tainly be  disappointed.  Apart  from  all  this,  however, 
it  is  possible  to  class  a  vast  number  of  the  subjects  of 
struma  according  to  the  types  I  have  described.  The 
test  applied  to  effect  this  classification  need  not  be 
elaborate.  If  with  one  aspect  of  scrofula  be  classed  all 
those  with  oval  faces,  regular  features,  and  fine  skin, 
and  with  the  other  aspect  those  with  broad  faces,  coarse 
features,  and  thick  skin,  an  approximate  result  will  be 
obtained  which  will  be  of  value. 

As  is  common  with  all  hard  and  fast  descriptions  of 
individuals,  a  large  number  of  the  strumous  belong  to  a 
kind  of  medium  type  between  the  two  just  given. 

Such  a  type  would  include  what  is  known  as  "  pretty 
struma."  The  general  features  of  individuals,  so  termed, 
belong  to  the  so-called  "  phlegmatic  "  type ;  but  the 
coarseness  of  the  features  is  toned  down  ;  the  lips  would 
be  called  "  full,"  not  tumid,  and  a  coarse  flabbiness  would 
subside  into  a  pretty  plump  condition  of  the  body. 
The  limbs,  if  not  actually  graceful,  are  at  least  prettily 
rounded.  The  skin  may  not  be  thin  and  fine,  but  it  is 
soft,  white,  and  clear.  The  general  expression  is  not 
absolutely  apathetic,  but  would  be  termed  rather  gentle, 
and  eminently  feminine.  An  excellent  representation 
of  "pretty  struma"  was  given  in  the  photographic 
series  above  alluded  to. 

The  practical  aspects  of  this  matter  of  physiognomy 
are  of  no  little  importance.  To  the  first,  or  so-called 
"  sanguine  "  *  type  belong  those  cases  of  scrofula  that 

*I  continue  to  retain  these  ancient  words  "sanguine"  and  "phleg- 
matic" for  want  of  better.     They  have  the  advantage  of  being  almost 


THE   SCROFULOUS   INDIVIDUAL.  85 

show  distinct  heredity,  and  especially  those  that  are  in 
some  way  or  another  intimately  associated  with  phthisis. 
Patients  in  whose  family  history  there  is  a  strong  ele- 
ment of  phthisis  or  tuberculosis  nearly  always  present 
the  features  of  this  class.  In  these  individuals  the 
tubercular  process  appears  to  reach  its  greatest  devel- 
opment, they  are  liable  to  the  more  severe  and  fatal 
forms  of  the  disease,  and  they  offer,  in  consequence,  the 
elements  of  a  somewhat  more  unfavorable  prognosis. 
The  physiognomy  is  identical,  as  before  remarked,  with 
that  accredited  to  phthisis  and  tuberculosis  generally ; 
and  the  few  cases  that  I  have  seen,  where  scrofulous 
subjects  have  succumbed  to  pulmonary  consumption  or 
general  tuberculosis,  have  been  individuals  of  this  class. 
It  must  not  for  a  moment  be  assumed  that  a  tendency 
to  the  graver  forms  of  tubercular  disease  is  peculiar  to 
such  of  the  strumous  as  have  this  physiognomy,  but  it 
certainly  is  more  usual  among  them,  and  I  think  that 
reported  cases  will  bear  out  this  assertion.  The  scrofula 
of  the  rich,  which  is  so  generally  independent  of  acquired 
causes,  has  usually  the  features  of  the  "  sanguine  "  type, 
and  the  graver  prognosis  of  the  disease  in  such  indi- 
viduals has  already  been  commented  upon.  The  term 
"  phthisical  form  of  scrofula  "  has  been  applied  to  this 
aspect  of  the  disease  when  the  physiognomy  is  well 
marked,  and  the  term  is  not  inappropriate  when  the 
associations  of  this  phase  of  the  malady  are  considered. 
Henning*  considers  this  phthisical  form  of  scrofula  to 
be  more  common  among  women,  but  I  am  unable  to 
express  any  opinion  upon  this  point. 

With  regard  to  the  "  phlegmatic  "  type  of  scrofula,  it 
is  the  type  usually  assumed  in  the  acquired  forms  of  the 
disease.  It  is  best  seen  perhaps  in  what  has  been  well 
termed  "  parochial  struma."  From  descriptions  given 
it  is  evident  that  the  large  amount  of  scrofula  at  one 
time  manufactured  by  penitentiaries  and  poor-houses 
was  of  this  character.    At  the  Margate  Infirmary,  where 


meaningless  with  regard  to  the  present  subject,  and  are  thus  useful  as 
pure  terms. 

*  "  Loc.  cit,"  p.  79 


86  THE  SCROFULOUS  INDIVIDUAL. 

the  patients  are  drawn  largely  from  the  poorer  classes, 
this  type  of  scrofula  is  very  commonly  to  be  met  with. 
Patients  with  these  peculiar  features  are  very  liable  to 
great  gland  enlargements  and  to  sluggish  affections  of 
mucous  surfaces  ;  they  show  little  or  no  tendency  to  the 
more  serious  forms  of  tubercular  disease,  and  although 
they  may  relapse  again  and  again,  are  very  readily  and 
satisfactorily  improved  by  treatment.  This  physiog- 
nomy is  certainly  the  one  most  peculiar  to  scrofula,  and 
deserves  of  all  others  the  designation  scrofulous  or 
strumous.  It  is  the  physiognomy  recognized  by  the 
older  writers,  and  upon  it  has  been  founded  the  most 
common  and  familiar  description  of  the  disease.  Pos- 
sibly it  is  less  commonly  met  with  now  than  in  years 
gone  by,  and  its  less  frequent  occurrence  would  accord 
with  a  diminution  both  in  the  number  and  in  the  gross- 
ness  of  the  examples  of  acquired  scrofula. 

This  matter  of  physiognomy  appears  to  further  illus- 
trate the  relationship  between  scrofula  and  phthisis 
upon  which  I  have  already  insisted.  Phthisis  is  met 
with  in  both  the  types  of  disease  already  described, 
although  it  is  much  more  commonly  associated  with 
the  so-called  sanguine  physiognomy.  Phthisical  individ- 
uals with  the  "  phlegmatic  "  type  of  face  are  spoken  of 
as  presenting' the  "  strumous  form  of  phthisis,"  just  as 
scrofulous  persons  of  the  sanguine  class  have  been 
referred  to  as  displaying  the  phthisical  form  of  struma. 
In  my  examination  of  the  phthisical  patients  at  the 
Brompton  Hospital,  above  referred  to,  only  one  out 
of  the  seven  who  had  evidence  of  scrofula  was  of 
the  phlegmatic  type  ;  all  the  others  possessed  more 
or  less  the  features  detailed  in  the  first-mentioned  class 
ol  the  disease.  A  propos  of  the  same  subject,  Laycock* 
and  others  state  that  it  is  difficult,  if  not  often  impossi- 
ble, to  distinguish  by  physiognomy  alone  scrofulous 
from  tuberculous  patients,  using  the  latter  term  in  its 
common  clinical  sense. 

I  will  now  discuss  in  detail  certain  features  more  or 
less  peculiar  to  the  scrofulous,  of  which  mention  has 

*Med.  Times  and  Gazette,  loc.  cit. ,  p.  341. 


THE   SCROFULOUS   INDIVIDUAL.  87 

not  yet  been  made,  or  which  have  been  merely  alluded 
to  en  passant. 

1.  The  Circulation  in  the  Scrofulous. — There  does  not 
appear  to  be  anything  peculiar  about  the  vascular 
arrangements  in  the  "  phthisical  form  of  scrofula,"  in 
those  individuals  who,  for  the  most  part  slight  and 
frail,  have  been  described  as  marking  the  sanguine  type 
or  the  disease.  But  in  the  coarser  type  of  struma 
defects  in  the  circulation  are  often  very  conspicuous. 
These  defects  have  been  frequently  alluded  to  by  various 
writers,  but  have  been  lately  especially  commented 
upon  by  Mr.  W.  K.  Treves,  of  Margate.*  In  these 
coarse,  flabby,  ungainly  children,  the  pulse  is  often 
below  the  average,  soft,  and  wanting  in  vigor.  The 
blood  appears  to  stagnate  in  exposed  parts,  and  thus 
the  cheeks  and  limbs  often  assume  a  bluish  or  mottled 
aspect.  Especially  is  this  seen  about  the  backs  of  the 
hands.  The  extremities  appear  swollen,  as  if  from 
cold,  and  the  skin  itself  feels  chilled  and  clammy.  All 
these  features  are  exaggerated  in  the  winter  and  npon 
exposure,  but  even  during  the  summer  weather  some  of 
these  children  retain  a  refreshing  aspect  of  chilliness. 
These  patients  are  particularly  liable  to  chilblains,  which 
often  take  on  a  very  unhealthy  action.  Indeed,  so  fre- 
quent is  this  ailment  that  it  forms  a  feature  in  the 
symptomatology  of  scrofula  ;  and  I  have  known  chil- 
dren to  be  troubled  with  "broken  "  chilblains  for  eight 
or  nine  months  out  of  the  twelve.  These  defects  in 
the  circulation  also  may  possibly  explain  the  frequent 
catarrhs  with  which  such  patients  are  afflicted,  and  may 
account,  as  Mr.  W.  K.  Treves  has  suggested,  for  the 
unwholesome  character  sometimes  noticed  in  their 
wounds.  As  to  the  cause  and  real  nature  of  these  cir- 
culatory defects  it  is  difficult  to  speak.  I  believe  them 
to  be  consequent  upon  defects  in  the  absorbent  system, 
and  on  this  point  would  fully  endorse  the  views  of  M. 
Potain.f     M.  Potain  has  fully  described  the  condition 

*"  The  condition  of  the  Circulation  in  Scrofula,"  by  W,  K.  Treves, 
F.R.C.S.  Lancet,  vol,  i.  i87l,p.  568.  From  this  article  I  have  derived 
the  main  points  of  the  description  that  follows. 

f  "  Art.  Lymphatique(pathologie),  Diet.  Encyclop.  des  Sc.  Med,,"  vol. 
iii.  2nd  series,  p.  475. 


88  THE   SCROFULOUS   INDIVIDUAL. 

f 

just  depicted,  and  speaks  of  the  general  state  that  leads 
to  it  as  "  lymphatism."  From  a  flaw  in  the  absorbent 
apparatus,  there  appears  to  be  an  excess  of  nutritive 
juices  in  the  tissues,  they  indeed  linger  there  unabsorbed; 
as  a  consequence,  a  kind  of  solid  oedema  is  produced, 
and  the  parts  become  flabby  and  sodden.  From  this 
material,  that  should  have  been  removed,  a  flimsy  con- 
nective tissue  is  developed,  and  the  thickness  of  the 
subcutaneous  layer  of  that  tissne  thereby  increased. 
Such  a  block  in  the  capillary  area,  where  important 
blood  changes  are  taking  place,  may  well  affect  the  cir- 
culation, and  induce  a  vascular  stagnation  in  the  part. 
With  this  impeded  blood  current,  some  of  the  most 
characteristic  of  the  changes  above  described  would  be 
associated.  I  would  regard,  therefore,  these  defects  in 
the  circulation  of  certain  scrofulous  persons  as  secondary 
to  some  fault  in  the  lymphatic  apparatus,  and  such  an 
explanation  would  well  accord  with  what  I  have  tried 
to  show  is  an  essential  feature  of  the  disease. 

2.  Temperature. — Little  is  to  be  said  upon  this  point, 
and  further  information  is  wanted.  Dr.  Lucien  Deligny* 
states  that  in  more  than  one  hundred  distinctly  scrofu- 
lous children  examined  by  him  at  l'Hopital  de  Berck, 
there  was  a  lowering  of  temperature  from  one-half  to 
one  degree.  These  patients,  of  course,  were  free  from 
active  inflammatory  processes.  He  concludes,  there- 
fore, that  in  the  scrofulous  the  temperature — apart  from 
all  inflammation — is  below  normal. 

3.  In  connection  with  this  subject  of  circulation  and 
temperature,  it  may  be  observed  that  acute  sthenic 
inflammations  are  comparatively  rare  in  the  scrofulous, 
especially  in  those  of  the  "  phlegmatic  "  type.  It  has 
also  been  asserted  that  general  fevers  are  not  apt  to 
run  high  in  such  individuals,  but  to  be  on  the  other 
hand  somewhat  unduly  protracted.  During  an  epidemic 
of  scarlet  fever  at  the  Margate  Infirmary  for  scrofula 
some  years  ago  I  observed  many  cases  that  appeared  to 
support  his  assertion. 

*'  De  l'Adenopathic  cervicale  chez  les  Scrofuleux."  These,  No.  469, 
1876,  p.  25. 


THE   SCROFULOUS   INDIVIDUAL.  89 

4.  Menstruation. — Some  assert  that  the  first  appear- 
ance of  menstruation  is  delayed  in  the  strumous,  and 
others  that  puberty  appears  at  an  earlier  age  in  such 
individuals.  In  thirty-nine  scrofulous  females  reported 
on  by  Lebert  twelve  began  to  menstruate  before  six- 
teen, fifteen  during  the  sixteenth  year,  and  the  remain- 
ing twelve  after  that  age.  I  believe  that  this  delay  in 
menstruation  is  only  to  be  met  with  in  some  of  those 
patients  who  exhibit  marked  defects  in  the  circulation, 
and  in  those  also  who  are  suffering  from  some  scrofulous 
disease,  inducing  anaemia  at  the  time  when  the  function 
should  be  established.  Apart  from  this,  I  imagine  that 
scrofula  has  no  effect  upon  the  appearance  of  puberty. 

In  analysing  the  records  of  the  Margate  Infirmary — 
which  records  include  accounts  of  females  of  all  ages — 
I  was  struck  with  the  great  number  who  were  stated  to 
be  suffering,  or  to  have  suffered,  from  dysmenorrhcea. 
I  imagine  this  number  to  be  much  in  excess  of  that  that 
would  obtain  among  a  like  number  of  healthy  girls  and 
women.* 

5.  Intelligence. — The  most  varied  accounts  have  been 
given  of  the  mental  condition  of  the  scrofulous.  They 
have  been  accused  of  displaying  precocious  sexual  pas- 
sions, and  have  been  credited  with  an  absence  of  those 
impulses.  They  have  been  distinguished  by  the  posses- 
sion of  certain  faculties  by  one  writer,  and  by  the  lack 
of  the  same  by  another.  An  observer  who  goes  more 
into  detail  sagely  remarks  that  in  the  scrofulous  "  the 
imaginative  faculty  preponderates  over  the  reflective," 
while  another  has  discovered  that  the  great  feature  of 
the  strumous  mind  is  a  "gentleness  of  disposition  and  a 
refinement  and  judgment  in  matters  of  taste."  With- 
out raking  up  more  of  the  ghastly  examples  of  human 
error  that  lie  buried  in  the  pages  of  ancient  books,  I 
might  allude  to  a  very  common  statement,  repeated 
over  and  over  again,  to  the  effect  that  scrofulous  chil- 
dren are  unduly  intelligent  and  precocious.  I  believe 
this  to  be  incorrect.     One  does   meet   with  precocious 

*  Lugol  refers  to  the  frequency  of  dysmenorrhcea  among  the  strumous, 
but  gives  no  details. 


go  THE   SCROFULOUS   INDIVIDUAL; 

children  among  the  strumous,  but  that  precocity  is  by 
no  means  peculiar.  I  think  such  instances  are  to  be 
explained  in  this  way.  The  scrofulous  child  is  the 
delicate  one  of  the  family  perhaps,  it  is  petted,  has 
more  notice  taken  of  it,  and  is  offered  every  facility  for 
the  development  of  the  points  that  make  up  the  "  pre- 
cocious infant."  Some  of  the  poorest  children  spend 
half  of  their  earlier  years  in  one  institution  or  another, 
and  by  mixing  with  older  children,  and  receiving  more 
attention  from  their  elders,  soon  begin  to  compare  in 
intelligence  with  their  brothers  and  sisters,  who  are  per- 
haps indulging  in  no  more  intellectual  pursuit  than  that 
of  crawling  from  one  gutter  to  another.  Moreover,  the 
prettiness  of  some  strumous  children  attracts  more 
attention  to  them  than  the  bulk  of  the  sickly  would 
perhaps  receive. 

I  knew  a  strumous  boy,  aged  ten,  who  conceived  a 
plan  of  extracting  money  from  the  hospital  money-box 
by  an  ingenious  contrivance  framed  from  a  piece  of  fire- 
wood and  some  plaster.  His  success  was  great.  It 
would  be  unfair  to  such  a  lad  to  ascribe  his  ill-applied 
ingenuity  to  scrofula.     He  was  a  natural  genius. 

6.  Certain  peculiar  features.  Hairiness. — In  young 
scrofulous  children  one  often  observes  an  amount  of 
close-lying,  downy  hair  upon  the  forehead,  especially 
about  the  sides  of  the  forehead.  A  like  condition 
may  often  be  seen  on  the  arms  and  upon  the  back, 
from  the  occiput  to  just  below  the  shoulders.  As  the 
child  grows  up  this  hair  becomes  less  conspicuous,  or 
disappears.  In  all  the  cases  I  have  seen  the  downy 
growth  was  very  fair.  Dr.  Wilshire*  was,  I  believe,  the 
first  to  call  attention  to  this  condition,  and  he  regarded 
it  as  quite  indicative  of  scrofula. 

The  value  of  this  sign,  however,  cannot  be  main- 
tained until  its  absence  in  healthy  children  has  been 
demonstrated,  and  its  limitation  to  scrofula  or  tuber- 
culosis clearly  made  out.  I  have  seen  a  certain  amount 
of  downiness  of  the  forehead  in  young  children,  in  whom 
there  was  no  reason  to  suspect  scrofula  or  tubercle. 

*  Medical  Times  and  Gazette,  April  10,  1847. 


THE   SCROFULOUS   INDIVIDUAL.  91 

Ears. — Dr.  Constantine  Paul*  has  drawn  attention  to 
certain  changes  in  the  ears,  after  they  have  been 
pierced  by  ear-rings,  that  he  considers  to  be  diagnostic 
of  scrofula.  The  puncture  in  these  cases  very  slowly 
ulcerates,  the  weight  of  the  ear-rings  directs  the  process 
downwards,  and  a  linear  scar  is  produced,  or  the  ear- 
ring may  cut  its  way  out,  leaving  a  slit,  or  instead  of  a 
scar  a  linear  aperture  may  be  formed  in  the  lobule.  If 
after  the  ear-ring  has  cut  its  way  out  the  lobule  be 
re-pierced,  it  may  cut  its'  way  out  again,  and  this  may 
occur  three  or  four  times,  a  considerable  amount  of 
deformity  being  produced.  He  gives  details  of  114 
cases.  In  96  of  these  cases  the  patients  presented 
either  scars  of  scrofula  or  some  distinct  manifestations 
of  the  disease.  In  18  there  were  no  direct  evidences  of 
struma.  In  51  cases  the  duration  of  the  ulcerative  pro- 
cess was  noted,  and  was  found  to  average  4  years  and 
2  months.  In  74  instances  both  ears  were  affected,  in 
38  one  ear  only.  Age  appears  to  have  no  influence  in 
producing  the  scars,  and  in  the  bulk  of  the  cases  the 
ears  were  pierced  in  infancy  or  childhood.  From  all 
these  cases  accidents  were  excluded.  He  concludes 
with  the  observation  that  every  female  in  whose  ears 
the  scar  left  by  piercing  is  not  a  simple  orifice,  but  pre- 
sents instead  a  slit-like  aperture  or  a  linear  cicatrix,  is 
the  subject  of  scrofula.  Dr.  Paul  states  that  these 
scars  and  slits  in  the  ears  are  very  common.  Since  the 
publication  of  his  paper  I  have  examined  a  large  num- 
ber of  women  for  these  changes  in  the  lobule,  and  I 
have  found  so  few  examples,  that,  in  London,  at  least, 
I  apprehend  such  ears  are  rare.  Possibly  on  the  Conti- 
nent ear-rings  are  more  frequently  worn  than  in  Eng- 
land, and  they  are  certainly  often  of  greater  size  and 
weight.  In  all  the  examples  of  these  ear  changes  that 
have  come  under  my  notice  the  subjects  were  scrofulous, 
except  in  one  case  where  the  ear-rings  had  cut  their 
way  out  on  both  sides  no  less  than  three  times.  The 
woman  was  30  years  of  age,  free  from  any  scrofula  past 


*  "  Un  nouveau  Signe  de  la  Scrofule  fourni  par  les  Boucles  d'Oreille." 
L  Union  Medicate  February,  1881,  p.  337-  et  seq. 


92  THE   SCROFULOUS   INDIVIDUAL. 

or  present,  but  very  cachectic  from  syphilis  acquired 
years  ago.  There  was  a  vague  history  of  phthisis  in 
her  family.  Before  "accepting  Dr.  Paul's  very  positive 
assertion,  I  think  these  questions  should  be  answered ; 
If  the  condition  is  due  to  general  tissue  defects,  how 
comes  it  that  in  38  out  of  112  instances  only  one  ear 
was  affected?  How  are  the  18  cases  to  be  explained  where, 
.  as  Dr.  Paul  allows,  there  were  no  traces  of  scrofula  ? 
and  lastly,  is  there  no  connection  between  the  lesion 
and  the  weight  of  the  ear-ring  and  the  metal  of  which 
it  is  composed  ?  I  must,  moreover,  state  that  in  many 
of  the  cases  detailed  by  Dr.  Paul  the  evidence  of  the 
existence  of  scrofula  is  of  the  most  scanty,  and  often 
of  the  most  doubtful  character. 

Lips. — The  thick  upper  lip  of  the  strumous  which  is 
never  absent  from  the  older  descriptions  of  physiog- 
nomy is  due,  as  before  stated,  to  some  irritation,  usually 
to  acrid  discharge  from  the  nose.  A  like  cause  will 
probably  explain  the  thick  alae  of  the  nose  observed  in 
some  cases,  and  also  a  thickening  of  the  inferior  and 
anterior  point  of  the  nasal  septum  that  is  not  uncom- 
mon in  struma. 

A  red  line  on  the  gums  has  been  described  as  an  out- 
ward and  visible  sign  of  scrofula.  Ruehle,  describing 
the  physiognomy  of  phthisical,  speaks  of  its  existence 
as  among  the  features  that  would  arouse  a  suspicion 
of  phthisis.  Various  interpretations  have  been  given 
to  it,  and  Ruehle  simply  describes  it  as  "  a  sharply 
defined  red  line  at  the  edge  of  the  gums,  opposite  the 
incisor  and  canine  teeth."  * 

The  teeth  in  scrofula  show  nothing  distinctive.  In 
many  strumous  individuals  the  teeth  are  normal  in 
every  respect,  although,  as  occurs  in  other  conditions  of 
ill-health,  dentition  is  often  irregular  or  delayed.  Often 
the  teeth  are  uneven  or  projecting,  or  present  milk- 
white  spots  indicative  of  defects  in  the  enamel.f  In 
other  cases  they  appear  to  be  brittle,  are  apt  to  scale 
off  or  break,  and  to  become  prematurely  carious.    These 

*"  Loc.  cit."  p.  510. 

f  D.  Laycock,  Med.  Times,   "loc.  cit.,  p.  449. 


THE   SCROFULOUS   INDIVIDUAL.  93 

varions  features  are,  however,  by  no  means  peculiar  to 
scrofula,  although  often  met  with  in  that  disease ;  and 
the  condition  upon  which  these  modifications  from  the 
normal  state  depend  are,  I  think,  still  unknown.  One 
of  the  commonest  aspects  of  the  teeth  in  struma  is 
that  figured  by  Mr.  Hutchinson,*  who  has  given  a 
drawing  of  the  upper  central  incisors  of  the  permanent 
set  from  "  a  very  scrofulous  boy."  These  teeth  are 
very  large,  white,  well-formed,  and  almost  quite  square. 
They  are  possessed,  moreover,  of  a  sharp,  clean  edge. 
Although  not  peculiar  to  scrofula,  I  have  met  with 
these  teeth  more  often  in  that  disorder  than  in  any 
other. 

Clubbed  fingers  are  not  common  in  the  scrofulous. 
Trousseau  had  not  met  with  an  instance,  although  not 
a  few  authors  have  connected  this  deformity  with  the 
disease.  Clubbed  fingers,  under  whatever  circumstances 
they  occur,  appear  to  be  due  to  impeded  circulation,  to 
retardation  in  the  return  of  venous  blood,  perhaps  also 
to  imperfect  oxygenation  of  the  blood.  The  condition 
appears  to  be  most  common  in  congenital  heart  disease,  f 
in  phthisis,  empyema,^  and  chronic  lung  affection  and 
certain  thoracic  aneurisms.§  In  all  these  circumstan- 
ces I  imagine  that  the  explanation  just  given  would 
hold  good.  I  have  only  met  with  one  case  of  finger 
clubbing  in  scrofula,  and  that  case  was  a  very  marked 
one.  The  patient  was  a  boy,  aged  10,  with  well-pro- 
nounced features  of  the  so-called  phlegmatic  type  of 
scrofula.  There  were  a  few  enlarged  glands  on  both 
sides  of  the  neck,  especially  about"  its  base,  and  some 
scars  in  the  skin  of  less  recent  glandular  mischief.  The 
fingers  of  the  left  hand  were  very  clubbed,  those  of  the 
right  being  less  conspicuously  effected.  In  both  axillae 
enlarged  gland  could  be  felt  that  occupied  the  extreme 
apex  of  the  space.  These  glands  had  not  attracted  the 
notice  of  either  the  patient  or  his   mother,  and  formed 

*  "  Illustrations  o    Clinical  Surgery,  vol.  ii. ,  1879,  plate  43. 
f  See  figure  in  Dr.  Laycock's  article. 
1  Dr.  Ogle.     Med .  Times,  vol.  1.  1859,  p.  291. 

§  Dr.  Meadows.     Med.   Times,  same  vol.  p.  377.   I  quote  these  merely 
as  examples. 


94  THE  SCROFULOUS  INDIVIDUAL. 

masses  of  no  great  size.  The  collection  on  the  left  side 
was  the  larger,  and  formed  a  clump  about  the  size  of  a 
duck's  egg.  The  lad  was  the  eldest  child  of  five,  and 
the  only  one  of  the  family  who  presented  traces  of 
scrofula.  The  father  died  at  the  age  of  42  of  supposed 
phthisis.  I  would  maintain  that  in  this  case  the  cause 
of  the  clubbed  fingers  was  purely  mechanical,  and  due 
to  pressure  exercised,  most  probably,  upon  the  axillary 
vein,  by  the  gland  masses  wedged  in  the  apex  of  each 
axilla.  The  cold  and  purplish  color  of  the  hands  quite 
supported  this' idea.  Such  a  case  as  this  appears  to  me 
to  be  parallel  to  one  recorded  by  Dr.  Ogle,*  of  St. 
George's  Hospital,  where  a  healthy  man  with  an  aneur- 
ism of  the  subclavian  artery  developed  clubbed  fingers 
on  the  affected  side. 

The  General  Manifestations  of  Scrofula. — Of  the 
history  of  the  scrofulous  individual,  of  the  tendencies 
to  disease  he  exhibits,  and  of  the  actual  affections  to 
which  he  is  prone,  I  can  only  speak  in  the  briefest  pos- 
sible manner,  and  will  attempt  little  more  than  an 
enumeration  of  the  more  common  outcomes  of  the  mal- 
ady. Bazin  has  attempted  to  divide  scrofula  into  four 
periods — primary,  secondary,  tertiary,  quaternary ;  and 
has  endeavored  to  establish  a  sequence  in  strumous 
manifestations  akin  to  the  very  definite  sequence  of 
morbid  processes  observed  in  syphilis.  Bazin's  division, 
however,  is  arbitrary,  artificial,  and  certainly  without 
clinical  foundation.  His  fourth  period  includes  affec- 
tions, such  as  phthisis,  tubercular  peritonitis,  and  amy- 
loid degeneration  of  viscera,  that  cannot  be  classed  as 
scrofulous  without  effecting  a  great  and  undesirable 
reform  in  the  common  significance  of  that  term.  As 
regards  the  sequence  of  diseases  that  his  periods  imply, 
it  is  possible  that  an  individual  may  here  and  there  be 
met  with  who  would  show  such  sequence ;  but  at  the 
same  time  I  think  it  would  be  allowed  that  the  circum- 
stances were  rather  accidental  than  the  outcome  of  a 
great  pathological  principle.  Scrofulous  disease  may 
first  show  itself  by  some  manifestation  of  Bazin's  ter- 

*  Med.  Times  and  Gazette,  vol.  i.  1859,  p:  261. 


THE   SCROFULOUS   INDIVIDUAL.  95 

tiary  period — as,  for  example,  by  a  joint  affection — and 
then  proceed  to  the  secondary  or  primary  disorders  of 
his  list,  the  patient  becoming  the  subject  of  an  eczema 
or  a  lupus.  Commonly  enough  one  finds  a  patient 
exhibiting  throughout  his  whole  life  but  one  mani- 
festation of  one  of  Bazin's  periods,  and  showing 
no  other  evidence  of  scrofulous  disease.  How 
often,  for  instance,  does  lupus  form  the  sole  mani- 
festation of  scrofula !  and  how  often  in  strumous 
children  is  a  carious  spine  the  only  outcome 
of  the  malady  !  Scrofula,  moreover,  often  appears  to  be 
abortive ;  an  infant  presents  an  eczematous  eruption 
abovt  its  head,  or  developes  a  phlyctcenular  ophthalmia, 
and  this  may  be  followed  perhaps  by  more  or  less 
gland  enlargement,  but  there  the  affection  ends — ends 
often  abruptly,  and  the  child  grows  up  healthy  and 
strong. 

In  opposing,  therefore,  in  general  terms  Bazin's  notion 
of  the  evolution  of  this  disease,  I  would  venture  to 
assert  that  the  progress  of  scrofula  is  most  capricious 
and  uncertain,  its  manifestations  most  variable,  and 
untrammelled  by  any  restriction  as  to  order  of  appear- 
ing. 

The  various  ailments  of  the  scrofulous  may,  I  think, 
be  most  conveniently  dealt  with  according  to  the  tissues 
or  structure  they  involve. 

Skin  Affections. — It  is  doubtful  if  one  can  consider 
any  skin  disease,  with  the  exception,  perhaps,  of  com- 
mon lupus,  as  peculiar  to  scrofula.  The  skin  affections 
that  occur  in  the  scrofulous  have,  it  is  true,  some  pecu- 
liarities, and  exhibit  certain  tendencies  that  may  be 
more  or  less  characteristic ;  but  these  few  special  fea- 
tures cannot  place  such  affections  in  a  special  class,  and 
cannot  support  any  claim  that  they  should  be  regarded 
as  distinct  forms  of  skin  disease. 

Those  who,  with  Hardy*  and  Bazin,f  maintain  a 
peculiar  form  of  cutaneous  affection — the  scrofulide — ■ 

"  Des  differentes  Formes  des  Scrofules  cutanees   ou    Scrofulides." 
"Gaz.  des  Hop.,"  1854,  No.  115. 

f  "Art.  Scrofulides,  Diet.  Encycl.  des  Sciences  Med."  Paris,  1880,  p. 
355- 


g6  THE   SCROFULOUS   INDIVIDUAL. 

must,  I  think,  confess  that  the  distinctions  they  lay 
down  are  somewhat  scanty,  a  little  artificial,  and  a  good 
deal  limited  in  their  application. 

One  of  the  commonest  skin  disorders  prone  to  affect 
the  scrofulous  is  the  erytheme  pernio,  or  chilblain. 
This  affection  particularly  occurs  in  those  patients  who 
exhibit  the  so-called  phlegmatic  aspect  of  struma ;  and, 
indeed,  in  such  individuals  a  history  of  chilblain  is  not 
commonly  absent. 

In  many  strumous  patients  there  appears  to  be  no 
difference  between  the  chilblains  they  present  and  those 
that  occur  in  non-scrofulous  individuals.  Commonly, 
however,  the  strumous  chilblain  assumes  a  more  special 
aspect.  It  is  apt  to  be  associated  with  a  greater  amount 
of  swelling,  and  with  more  thickening  of  the  deeper 
parts  than  is  usual  in  this  form  of  erythema.  It  is  apt, 
moreover,  to  persist,  to  relapse,  and  to  lead  to  trouble- 
some and  prolonged  ulceration.  Chilblains  will  often 
continue  to  inflict  strumous  patients  for  nine  or  ten 
months  out  of  the  twelve,  and  I  have  seen  cases  where 
they  have  persisted  all  the  year  round.  In  such  per- 
sons, also,  the  ulceration  is  often  very  marked,  and  may 
assume  more  the  aspect  of  those  ulcerating  chilblains 
that  are  sometimes  met  with  upon  the  toes  of  paralyzed 
limbs,  especially  in  cases  of  infantile  paralysis.  I 
believe  that  erythema  pernio  of  the  fingers  is  much 
more  common  in  the  scrofulous  than  in  individuals  in 
any  other  condition  of  general  ill-health. 

Eczema  is,  next  to  chilblains,  the  commonest  skin 
affection  of  the  strumous.  It  very  usually  appears  as 
the  first  manifestation  of  scrofula,  and  is  of  much  more 
frequent  occurrence  between  the  first  and  second  denti- 
tions than  at  any  other  time.  Its  especial  features — 
such  as  they  are — are  these : — It  is  apt  to  be  chronic, 
and  to  show  little  tendency  to  spontaneous  cure.  It  is 
seldom  extensive,  is  little  prone  to  recurrence,  and 
selects  as  it  favorite  sites,  the  scalp,  the  furrow  behind 
the  ears,  the  concha  itself,  and  the  face,  especially  the 
parts  about  the  lips  and  nostrils.  In  these  latter  situ- 
ations it  is  often  secondary  to  some  discharge  from  the 
nose  or  some  unhealthy  condition  of   the   mouth    or 


THE   SCROFULOUS   INDIVIDUAL.  97 

tongue.  The  eruption  itself  is  usually  very  moist,  and 
its  secretion  tends  to  become  pustular,  leading  thereby 
to  that  form  of  eczema  known  as  eczema  impetiginodes. 
When  about  the  head  or  face  it  is  as  a  rule  associated 
with  an  enlargement  of  the  cervical  glands  that  seldom 
assumes  any  great  magnitude.  In  strumous  infants 
and  young  children  this  eczema  is  often  followed  by 
certain  superficial  abscesses  that  appear  in  or  about  the 
affected  district  as  the  eruption  subsides.  This  espe- 
cially applies  to  eczema  of  the  scalp.  These  abscesses 
are  very  superficial,  are  covered  by  a  thinned  and  pur- 
plish-red integument,  and  cause  neither  pain  nor  other 
inconvenience.  If  left  alone  they  break  and  usually  do 
well,  or  at  any  time  their  course  maybe  very  effectively 
cut  short  by  a  minute  puncture  with  the  thermo-cautery 
point. 

These  eczematous  eruptions  form  a  conspicuous  fea- 
ture in  Bazin's  "  first  period "  of  scrofula,  and  are 
prominent  among  the  "  benign  scrofulides  "  of  those 
who  maintain  a  distinctive  character  for  the  skin  disor- 
ders of  the  strumous. 

Lupus. — It  is  impossible  in  this  place  to  attempt  even 
a  sketch  of  this  important  skin  disease  and  its  various 
aspects.  It  constitutes  one  of  the  gravest  outcomes  of 
struma,  and  has  received  much  attention  as  well  from 
the  pathologist  as  from  the  practical  surgeon.  I  pro- 
pose here  to  consider  merely  the  question  as  to  how  far 
lupus  is  to  be  regarded  as  a  scrofulous  affection,  as  an 
affection  peculiar  to  the  strumous.  The  matter  may  be 
considered  from  both  a  clinical  and  a  pathological  point 
of  view.  Clinically  it  must  be  owned  that  the  bulk  of 
the  cases  of  ordinary  lupus  occur  in  scrofulous  sub- 
jects. I  exclude,  of  course,  from  this  question  that 
eruption  common  in  tertiary  syphilis,  and  known  as  the 
"tubercular  syphilide,"  or  as  syphilitic  lupus.  This 
disease  certainly  resembles  common  lupus  both  in 
aspect  and  to  some  extent  in  tendency,  but  that  resem- 
blance is  only  superficial.  In  syphilitic  lupus  we  have 
— as  Mr.  Hutchinson  would  express  it — an  example  of 
syphilis  imitating  a  well-known  skin-affection.  It  is  an 
imitation  merely,  and  upon  the  grounds  of  general 
7 


98  THE   SCROFULOUS   INDIVIDUAL. 

pathology  the  two  diseases  are  not  identical.  Excep- 
tion must  also  be  made  in  the  present  instance  to  the 
various  forces  of  acquired  lupus.  This  variety  of  lupus 
would  appear  to  be  due  to  accidental  inoculation  with 
certain  animal  matters  in  a  state  of  decay,  and  occurs 
independently  of  struma  or  any  other  diathesis.  The 
ordinary  forms  of  lupus — untouched  by  these  reserva- 
tions— have  great  claims  to  be  regarded  as  scrofulous 
diseases ;  and  if  there  is  a  skin  affection  peculiar  to 
struma  I  think  that  affection  would  be  lupus. 

Examples  are  certainly  met  with  of  lupus  in  indi- 
viduals who  present  no  familiar  or  recognized  token  of 
scrofula,  but,  as  I  have  already  pointed  out,  undoubted 
strumous  affections  may  appear  in  persons  who  are  of 
perfectly  healthy  aspect.  A  closer  examination  of 
apparent  instances  of  lupus  attacking  non-scrofulous 
patients  will  give  results  such  as  these : — There  is  a 
history  of  phthisis  in  the  family,  or  one  or  other  of 
the  parents  was  scrofulous  in  youth,  or  a  brother 
or  sister  of  the  patient  shows  evidence  of  undoubted 
struma,  or  the  patient  himself  has  some  of  the  ten- 
dencies of  the  scrofulous  in  a  slight  degree — a  dis- 
position to  catarrh  after  trifling  exciting  causes,  and 
a  tendency  for  such  affection  to  become  chronic  and 
relapse. 

From  a  pathological  point  of  view  lupus  shows  a 
most  close  alliance  to  recognized  scrofulous  disorders. 
The  lupoid  process  is  chronic,  is  apt  to  relapse,  extends 
locally,  as  if  by  direct  infection  of  adjacent  parts,  and 
has  products  that  show  a  marked  disposition  to  degen- 
erate. One  important  feature  is  absent — the  tendency 
to  gland  implication  ;  and  the  rarity  of  this  complica- 
tion is  a  great  argument  in  the  hands  of  those  who  deny 
the  essentially  scrofulous  nature  of  lupus.  Lupus,  how- 
ever, in  spite  of  this,  would  appear  to  have — like  other 
strumous  disease — a  predilection  for  lymphatic  tissues  ; 
for  it  is  very  apt  to  occur  about  parts  where  skin  and 
mucous  membrane  join,  and  to  be  very  destructive  in 
those  situations ;  and  it  is  well  known  that  in  such 
localities — as,  for  example,  about  the  mouth  and  nos- 
trils— the  lymphatic  networks  are  particularly  numerous 


THE   SCROFULOUS   INDIVIDUAL.  99 

and  extensive.  Mr.  Hutchinson,*  moreover,  has  sug- 
gested that  the  lupoid  process  extends  by  means  of  the 
lymphatic  channels  of  the  part. 

Microscopically,  the  changes  in  lupus  are  essentially 
scrofulous.  In  some  cases  distinct  follicular  tubercles 
are  met  with  in  the  diseased  area,  and  in  other  instances 
a  less  perfect  formation  of  tubercle  is  the  principal  fea- 
ture. In  perhaps  the  bulk  of  cases,  in  the  place  of 
perfect  tubercle  a  granulation  tissue  is  met  with  associ- 
ated with  giant  cells,  and  some  few  of  the  large  cell  ele- 
ments so  peculiar  to  scrofulous  processes,  f  So  far, 
indeed,  as  the  microscope  is  concerned  the  lupoid  pro- 
cess would  appear  to  be  actually  identical  with  recog- 
nized strumous  changes ;  and  this  fact,  in  addition  to 
clinical  and  other  evidence,  would  support  the  belief 
that  lupus  is  as  definite  a  scrofulous  affection  as  scrof- 
ula itself  is  a  definite  morbid  condition.  This  observa- 
tion would  apply  only  to  ordinary  lupus,  and  would  not 
therefore  imply  that  every  form  of  lupoid  disease  is  of 
an  essentially  scrofulous  character. 

The  Lichen  Scrofitlosorum  of  Hebra,  while  it  is  not 
restricted  to  the  strumous,  is  certainly  most  common 
among  individuals  of  that  class.  In  ninety  per  cent,  of 
the  cases  of  this  skin  affection  observed  by  Hebra, 
either  there  were  such  distinct  evidences  of  scrofula  as 
gland  disease,  caries,  and  strumous  ulceration,  or  the  pa- 
tients were  the  subjects  of  mesenteric  disease,  with  its 
attendant  mal-nutrition.  This  cutaneous  affection  oc- 
curs for  the  most  part  in  young  people  between  the 
ages  of  10  and  25,  and  assumes  the  form  of  roundish 
groups  of  papules  about  the  size  of  millet  seeds,  and  of 
a  reddish  or  faint  brown  color.  Sometimes  they  are  of 
the  same  tint  as  the  adjacent  skin,  and  according  to 
Dr.  Tilbury  Fox  may  not  occur  in  groups,  but  be  more 
diffused  in  their  arrangement. 

These  patches  of  eruption  appear  usually  upon  the 
trunk,  tend  to  take  on  a  very  chronic  course,  and  to 
frequently    reappear.     They   are    generally    associated 


*  "British  Med.  Journ.,"  Vol.  I.,  1880. 
\  See  paper  by  Dr.  Grancher  in  L'  Union  Medicaid.  1881,  p.  874. 


IOO  THE  SCROFULOUS  INDIVIDUAL. 

with  certain  spots,  like  those  of  common  acne,  and  the 
whole  eruption  is,  as  a  rule,  most  satisfactorily  treated 
by  general  measures.  Lichen  and  scrofulosorum  appears 
to  be  of  much  greater  frequency  in  male  individuals, 
but  is  not  limited  to  that  sex,  as  was  originally  main- 
tained. In  an  article  in  the  "  Transactions "  of  the 
Clinical  Society  of  London,  Dr.  Tilbury  Fox  gives  an 
excellent  representation  in  chromo-lithography  of  this 
eruption,  and  furnishes  details  of  several  cases,*  the 
bulk  of  which  are  oddly  enough  in  females. 

With  regard  to  other  skin  eruptions,  it  has  been  fre- 
quently maintained  that  certain  parasitic  affections  are 
of  more  common  occurrence  among  scrofulous  than 
among  healthy  individuals.  This  has  been  especially 
urged  with  regard  to  favus,  and  possibly  the  accusation 
is  true.  But  I  should  imagine  the  relation  between 
scrofula  and  parasitic  skin  disease  to  depend  merely 
upon  the  circumstance  that  the  conditions  of  squalor, 
dirt,  and  bad  hygiene,  so  suitable  for  the  development 
of  scrofula,  are  also  the  very  conditions  that  would 
most  favor  the  growth  and  spread  of  parasitic  affections. 
Favus,  I  believe,  is  almost  if  not  quite  unknown  among 
the  rich,  and  the  patients  among  whom  one  meets  with 
the  disease  are,  as  a  rule,  conspicuous  for  their  misera- 
ble surroundings  and  their  generally  neglected  condi- 
tion. If  a  child  has  its  head  full  of  lice  it  is  very 
reasonably  assumed  that  its  care  has  been  neglected ; 
and  if  the  mother  of  such  a  child  can  so  utterly  ignore 
the  practice  of  simple  cleanliness  as  to  allow  its  hair  to 
swarm  with  vermin,  she  is  probably  no  more  careful 
about  matters  of  diet,  regimen,  and  ventilation — mat- 
ters that  hold  a  prominent  position  in  the  etiology  of 
scrofula. 

Skin  affections,  other  than  those  already  alluded  to, 
do  not  appear  to  be  more  common  or  more  peculiar  in 
scrofulous  individuals  than  they  are  in  persons  exempt 
from  that  diathesis,     Lastly,  certain  rare  cutaneous  dis- 

*  Vol.  xii,  1879,  p.  140.  See  also  case  of  Lichen  S.  in  the  same  vol- 
ume (p.  195),  by  Dr.  H.  Radcliffe  Crocker.  Hebra's  account  of  the 
disease  will  be  found  in  vol.  ii.  of  his  work  "  On  Diseases  of  the  Skin," 
New  Syd.  Soc,  p.  52. 


THE   SCROFULOUS   INDIVIDUAL.  IOI 

orders  have  been  described  as  peculiar  to  scrofula  that 
have  in  reality  no  connection  with  that  disease,  but  are 
on  the  contrary  manifestations  of  hereditary  syphilis. 
As  examples  of  these  I  may  especially  cite  the  so-called 
"  impetigo  rodens  "  and  the  "  scrofulide  rupiforme  "  of 
Hardy.  Under  these  names  have  been  described  skin 
diseases  that  belong  undoubtedly  to  infantile  syphilis. 

Scrofuloiis  Gumma.  Cold  Abscess.  Strumous  Ulcer 
of  Skin. — These  variously  named  affections  may  be 
conveniently  described  together  for  reasons  that  will  be 
immediately  apparent.  Sometimes  in  scrofulous  sub- 
jects a  little  roundish  indurated  mass  may  be  felt  be- 
neath the  skin,  and  situate  in  the  subcutaneous  tissue. 
This  minute  hard  mass  when  first  noticed  may  be  the 
size  of  a  rice  grain  or  a  pea,  or,  on  the  other  hand,  as 
large  as  a  cherry.  At  first  moveable,  it  soon  becomes 
adherent  to  the  skin,  and  having  slowly  increased  in  size 
up  to  a  variable  point,  it  begins  to  soften  in  the  centre, 
the  skin  over  it  becomes  purplish,  gradually  thinned, 
and  at  last  gives  way.  Through  the  opening  so  formed 
a  thin  curdy  pus  escapes.  Such  a  small  subcutaneous 
nodule  when  it  attains  a  size  no  larger  perhaps  than  a 
walnut  is  commonly  known  as  a  scrofulous  gumma — ■ 
especially  by  French  writers.*  Very  frequently,  how- 
ever, the  subcutaneous  induration  increases,  the  skin 
remains  long  intact  and  unchanged,  and  by  subsequent 
breaking  down  of  the  hardened  mass  and  extension  of 
the  process,  a  large  collection  of  pus  is  formed;  and 
then  perhaps  the  term  cold  abscess  would  be  used. 
The  " gomme  scrofuleuse  "  and  the  superficial  cold  ab- 
scess are  indeed  pathologically  identical,  and  differ  only 
in  degree  and  extent.  Microscopic  examination  shows 
that  the  subcutaneous  mass  is  tubercular,  that  it  grad- 
ually softens  in  the  centre,  having  previously  exhibited 
a  caseous  change,  and  by  such  softening  forms  an  abscess 
cavity.  The  abscess  enlarges  by  the  invasion  of  the 
surrounding  parts  by  its  investing  wall ;  and  the  micro- 
scope here  also  shows  in  this  wall  follicular  tubercles 

*  For  recent  account  see  Art.  by  Brissaud  and  Josias,  "  Gommes 
Scrof. ,"  Revue'mens.  de  Med.  et  de  Chirurg.,  1879. 


102  THE    SCROFULOUS   INDIVIDUAL. 

and  all  the  various  grades  of  the  tubercular  process. 
Sir  William  Jenner*  some  years  ago  maintained  the 
tubercular  nature  of  these  subcutaneous  abscesses,  and 
Lannelongue  f  has  quite  recently  given  a  very  perfect 
demonstration  of  the  same  view. 

These  superficial  strumous  abscesses  may  occur  at 
any  age.  One  of  the  most  destructive  I  ever  saw  was 
in  a  man  25  years  of  age.  As  a  rule  they  occur  at  a 
much  earlier  period,  and  are  commonest  during  the  first 
five  or  six  years  of  life.  Dr.  Grancher  states  that  they 
are  more  common  in  the  acquired  forms  of  scrofula — a 
statement  I  am  disposed  to  endorse.  They  are  often 
met  with  on  the  trunk  than  on  the  limbs,  are  common 
about  the  face  and  neck,  and  I  think  especially  frequent 
upon  the  back.     They  may  be  single  or  multiple. 

This  tubercular  process  may  be,  of  course,  more 
deeply  seated  than  the  subcutaneous  tissues,  and  is  then 
very  often  associated  with  bone  changes.  The  abscess 
formed  under  such  conditions  cannot  be  considered 
here,  but  it  forms  a  collection  of  pus  that  in  English 
text-books  is  more  particularly  designated  "  a  cold 
abscess."  Sometimes  the  indurated  nodule  is  situated 
in  the  skin  itself.  In  this  position  it  never  attains  a 
large  size,  becomes  soon  apparent,  and  soon  terminates 
by  a  discharge  of  the  softened  matter  in  its  centre.  To 
these  purely  cutaneous  nodules  the  term  "  tuberculosis 
of  the  skin  "  has  been  especially  applied,  and.  Dr.  Vidal^j: 
has  elaborately  described  them,  under  the  title  of  cuta- 
neous "  tuberculomas."  This  process  is  distinguishable 
from  lupus  by  its  more  rapid  course,  its  limited  tend- 
ency to  extend,  and  certain  histological  features. 

It  is  from  the  bursting  of  a  subcutaneous  "gumma" 
that  the  scrofulous  ulcer  most  usually  results.  A  gland 
abscess  may  lead  to  such  an  ulcer,  as  may  also  a  "  tuber- 
culome  "  of  the  skin,  or  even  a  pustular  eruption  on  the 
skin,  but  the  commonest  cause  is  that  first  mentioned. 
In  cases  where  these  ulcers  form,  the  integument  has 


*  "On  Tuberculosis."     Med.  Times  and  Gazette,  vol.  ii.  1861,  p.  423. 

J"  Abces  Froids  et  Tuberculose  0?seuse."     Paris,  1881. 
"  L'Union  Medicale,"  1881,  p.  639. 


THE   SCROFULOUS   INDIVIDUAL.  103 

become  much  undermined  before  the  pus  has  found  an 
exit,  and  this  condition  of  the  skin,  together  with  an 
actual  extension  of  the  tubercular  process,  is  the  chief 
local  cause  of  the  chronicity  of  these  sores.  The 
strumous  ulcer  needs  no  description.  Its  irregular  out- 
line, its  purple,  thinned  and  undermined  edge,  its  base 
void  of  granulations,  or  crowded  with  those  elevations 
rising  up — large,  pale,  and  flabby— is  familiar  enough. 

A  special  form  of  cutaneous  erysipelas  has  been 
described  uuder  the  title  "  scrofulous  erysipelas."  It  is 
said  to  occur  independently  of  wound  or  injury,  to  con- 
spicuously involve  the  lymphatics,  to  be  more  common 
in  females,  and  about  the  age  of  puberty.*  The  details, 
however,  furnished  of  this  supposed  special  form  of 
erysipelas  are  very  scanty. 

Mucous  Membranes.  —  One  of  the  commonest  fea- 
tures in  scrofula  is  a  tendency  to  a  catarrh,  that  may 
be  induced  by  the  most  trifling  causes,  that  is  apt  to 
persist  long  after  the  primary  cause  has  ceased  to  act, 
and  that  is  disposed  to  relapse  and  resist  ordinary  treat- 
ment. The  mucous  secretion  in  such  catarrhs  is  gen- 
erally thick  and  profuse,  very  prone  to  become  muco- 
purulent, and  often,  it  would  appear,  endued  with  irri- 
tating properties,  as  shown  by  eczemas,  &c,  of  the  skin 
about  the  orifices  of  affected  mucous  cavities.  The 
more  accessible  mucous  surfaces  are,  I  think,  attacked 
in  this  order  of  frequency — the  pharynx,  the  conjunc- 
tiva, the  auditory  lining  membrane,  the  nose,  and  the 
genitals.  The  mucous  membrane  of  the  alimentary 
canal  and  of  the  bronchi  are  also  very  commonly  in- 
volved in  the  scrofulous.  In  the  mouth  and  pharynx 
the  most  conspicuous  feature  is  hypertrophy  of  the 
tonsils.  This  affection  is  almost  pathognomonic  of 
scrofula,  for  indeed  in  strumous  children  it  is  rare  not 
to  find  some  enlargement  either  of  the  tonsils  them- 
selves, or  at  least  of  the  masses  of  adenoid  tissue  at  the 
back  of  the  pharynx.     Such  adenoid  masses,  it  is  well 


*  Grancher  (loc.  cit.,  Diet.  Encyclop. ,  p.  334)  gives  an  account  and 
references.  See  also  account  of  case  of  tuherculo-caseous  erysipelas, 
reported  by  M.  Coigne,  and  detailed  in  London  Medical  Record,  Feb.  19, 
1873. 


104  THE   SCROFULOUS   INDIVIDUAL. 

known,  have  a  structure  identical  with  that  of  the 
tonsil.  These  enlarged  tonsils  are  nearly  invariably 
associated  with  the  appearance  of  a  gland  tumor  on 
either  side  of  the  neck,  and  situate  just  about  the  top 
of  the  great  cornu  of  the  hyoid  bone. 

I  presume  that  the  almost  constant  presence  of  this 
gland,  which  feels  rounded,  deeply  placed,  and  about 
the  size  of  an  hypertrophy  tonsil,  has  given  rise  to  the 
erroneous  impression  that-  enlarged  tonsils  can  be  felt 
externally.*  So  constant  are  these  enlarged  glands  in 
this  tonsillar  affection,  so  uniform  is  their  outline  and 
situation,  that  it  is  almost  possible  to  diagnose  the 
throat  affection  by  simply  examining  the  neck  with 
care. 

Dr.  Westf  states  that  hypertrophy  of  the  tonsils 
commences  usually  during  the  later  stages  of  the  first 
dentition,  and  seldom  attracts  notice  until  the  child  is 
three  years  old.  I  believe  that  in  many  cases  of  marked 
struma  it  commences  at  an  earlier  date.  I  had  under 
my  care  a  male  child,  aged  seven  months,  who  was 
suffering  from  cervical  gland  disease,  and  who  presented 
a  very  considerable  enlargement  of  both  tonsils.  M. 
Robert:}:  has  observed  the  affection  as  early  as  the  sixth 
month ;  and  a  systematic  examination  of  the  throats 
of  strumous  children  will  show  that  a  distinct  tonsillar 
hypertrophy  is  by  no  means  uncommon  before  the  age 
of  two  years.  The  "  angina  scrofulosa  "  of  some  French 
authors  §  would  appear  to  have  little  connection  with 
struma,  and  to  be  in  most  cases  either  a  syphilitic  or  a 
lupoid  ulceration.  Trelatf  has  given  a  good  description 
of  a  tubercular  ulcer  of  the  mouth  and  tongue  ;  but  the 
disorder  seems  to  be  rather  a  feature  of  those  patients 
who  in  the  common  clinical  sense  are  classed  as  tuber- 
cular.     The    ophthalmic   affections   of    the    scrofulous 

*  For  relations  of  tonsil  to  external  parts,  see  fig.  u,  "Bellamy's 
Surgical  Anatomy,"  1880,  p.  41. 

f  "  Diseases  of  Infancy  and  Childhood,"  6th  ed.,  1874,  p.  592. 

i  "  Bull.  General  de  Therap.,"  May,  1843.. 

§  Constantine  Paul  {Gaz.  hebdo?n.,  1871,  No.  47).  Landrieux  ("  Arch. 
Gen.  de  Med.,  1874,  p.  660). 

I  Note  sur  Vulcere  tuberc.  de  la  bouche  et  de  la  langue  (Arch.  Gen 
de  Med.,  1870,  vol.  xv.,  p.  35). 


THE   SCROFULOUS   INDIVIDUAL.  105 

consist  mainly  in  tinea  tarsi  and  phlyctenular  ophthal- 
mia. The  latter  affection  is  infinitely  more  common 
in  the  strumous  than  in  any  other  class  of  individuals, 
and  may  almost  be  considered  as  peculiar  to  the  scro- 
fulous diathesis.  Primary  disorders  in  the  deeper  parts 
of  the  globe  are  not  common  in  scrofula,  and  when  they 
do  occur  in  such  patients  appear  to  present  no  distinc- 
tive features.  Otorrhcea  is  one  of  the  commonest  and 
the  earliest  manifestations  of  scrofula.  The  discharge 
is  apt  to  become  purulent,  and  is  very  commonly 
attended  by  some  eczema  of  the  auricle.  Catarrhal 
otitis  media  is  geuerally  due  to  extension  of  mischief 
from  the  throat  or  nose.  It  is  a  serious  affection,  in  so 
far  as  that  it  may  at  any  time  take  on  suppurative 
action,  and  may  lead  to  necrosis  of  the  petrous  bone. 
I  would  venture  to  question  the  assertion  of  Birch- 
Hirschfeld*  that  "  scrofulosis  is  at  thebottom  of  the 
largest  number  of  cases  in  which  weakening  or  destruc- 
tion of  the  function  of  hearing  has  taken  place  during 
the  age  of  childhood."  I  believe,  on  the  contrary,  that 
the  largest  number  of  such  cases  would  be  claimed 
either  by  hereditary  syphilis  or  be  subsequent  to 
scarlatina  or  other  eruptive  fevers. 

Affections  of  the  genital  mucous  membrane  in  young 
scrofulous  females  are  by  no  means  uncommon.  The 
bulk  of  the  cases  of  "  infantile  leucorrhoea,"  of  blen- 
norrhea of  the  vagina,  and  of  catarrhal  vulvitis,  occur- 
ring either  in  quite  young  children  or  about  puberty, 
would  appear  to  be  associated  with  the  scrofulous 
disposition.!  Mr.  Cooper  Forster;};  has  described  a 
"strumous  ulcer  of  the  vagina"  as  occurring  in  young 
children,  but  the  evidence  that  such  ulcers  depend  upon 
scrofulosis  does  not  appear  to  be  very  convincing.  The 
bronchial  mucous  membrane  is  commonly  affected  in 
scrofula.  Strumous  children  often  develop  a  trouble- 
some cough  on  very  trifling  exposure,  and  may  become 
the  subjects  of  what  has  been  definitely  described  as 


*  Loc.  cit.,  "Ziemsen's  Cyclopedia,"  p.   795. 

f  Dr.   West,  loe.   cit.,  p,   756. 

%  "The  Surgical  Diseases  of  Children."   London,   i860,  p.  127. 


106  THE   SCROFULOUS   INDIVIDUAL. 

"  scrofulous  bronchitis."  Much  attention  has  been 
paid  to  the  pathology  of  this  latter  affection,  as  it  has 
appeared  to  afford  a  connecting  link  between  scrofula 
and  phthisis.  Such  a  link,  however,  is  only  demanded 
by  those  who  consider  the  two  disorders  to  be  allied  but 
not  identical."'5'  Affections  of  the  alimentary  tract  show 
themselves  by  that  much-discussed  disorder — "  strumous 
dyspepsia."  That  there  is  a  form  of  mal-digestion  at 
least  common  in  scrofula,  although  perhaps  not  limited 
to  that  disease,  must,  I  think,  be  allowed.  This  stru- 
mous dyspepsia  particularly  affects  individuals  of  the 
"  phlegmatic  type,"  and  shows  itself  by  a  capricious 
appetite,  an  almost  constantly  furred  tongue,  foetid 
breath,  and  a  tendency  to  constipation,  alternating  with 
diarrhoea.  In  such  persons  the  abdomen  is  often 
swollen,  the  skin  pasty,  the  aspect  dull  and  lethargic. 
In  instances  of  this  character  one  may  reasonably 
assume  that  there  is  a  catarrh  of  the  alimentary  tract 
not  unlike  that  so  common  in  more  easily  investigated 
parts,  but  there  would  appear  to  be  little  or  no  evidence 
to  show  that  this  catarrh  is  actually  the  cause,  and  in 
some  cases  the  sole  originator  of  scrofula,  as  has  been 
urged  by  some. 

Lupus  may  attack  the  mucous  membranes,  and  may 
be  either  primary  or  have  extended  from  the  skin.  It 
would  appear  to  be  of  most  common  occurrence  about 
the  mucous  lining  of  the  palate,  nose,  and  pharynx. 

Gland  disease  will  be  the  special  subject  of  the  second 
part  of  this  book. 

Diseases  of  bone  form  one  of  the  most  frequent  and 
most  serious  of  the  manifestations  of  scrofula.  The  bone 
affection  usually  assumes  the  form  of  caries,  and  is 
characterised  by  the  ease  with  which  it  may  be  induced, 
by  its  chronic  course,  its  tendency  to  spread,  to  relapse, 
and  to  exhibit  exacerbations.  It  seldom  ends  in  resolu- 
tion. This  tendency  to  caries  in  struma  contrasts 
markedly   with   the   bone    diseases  of   syphilis,   where 


*  An  excellent  drawing,  showing  the  changes  in  scrofulous  bronchitis, 
will  be  found  in  Dr.  T.  H.  Green's  work  on  "The  Pathology  of  Pul- 
monary Consumption."     London,  1878,  p.   27. 


THE   SCROFULOUS   INDIVIDUAL.  IC>7 

necrosis  and  periosteal  affections  are  so  common.  The 
bulk  of  scrofulous  bone  diseases  commence  between  the 
ages  of  5  and  20.  In  the  509  Margate  cases  there  are 
152  instances  of  bone  affection.  These  are  distributed 
as  follows;  Bones  of  the  foot,  35  ;  the  spine,  26  ;  bones 
of  the  leg  (mostly  the  tibia),  24;  femur,  17;  bones  of 
the  hand,  13;  pelvic  bones,  10;  bones  of  forearm,  8 ; 
of  skull,  8  ;  humerus,  7  ;  ribs,  2  ;  and  sternum,  2. 

It  must  be  remembered  that  these  statistics  apply 
only  to  in-patients,  and  the  unduly  low  number  assigned 
to  disease  of  the  bones  of  the  hands  is  probably  to  be 
explained  by  this  fact.  There  is  one  bone  affection  that 
would  appear  to  be  almost  exclusively  scrofulous.  I 
allude  to  strumous  dactylitis  (the  spina  ventosa  of  the 
French).  This  disease  usually  invades  the  phalanges, 
and  particularly  the  phalanges  of  the  hand.  It  nearly 
always  appears  in  young  children  under  the  age  of  five. 
Into  the  nature  of  the  morbid  change  in  dactylitis  I 
cannot  now  enter,  and  will  only  observe  that  the  disease 
appears  to  commence  always  in  the  interior  of  the  bone, 
to  gradually  expand  it,  and  ultimately  to  lead  to  its 
almost  complete  disorganisation.  I  have  an  opportu- 
nity of  examining  two  cases  microscopically,  and  in  both 
instances  the  mischief  had  undoubtedly  commenced  in 
the  interior  of  the  bone.  The  flask-shaped  appearance 
of  the  finger  is  most  characteristic,  especially  when  it  is 
later  on  associated  with  a  general  reddening  of  the  skin 
and  the  formation  of  several  unwholesome-looking 
sinuses.* 

Certain  joint  affections  are  common  in  the  strumous, 
and  are  clinically  known  by  the  vague  term  "  white 
swelling,"  or  the  more  precise  expression  "  fungous 
arthritis."  The  features  of  these  chronic  ill-conditioned 
joint  diseases  are  well  known.  The  morbid  process  is 
the  same  as  that  concerned  in  all  other  scrofulous 
manifestations,  and  some  of  the  most  typical  examples 
of  tubercle  are  to  be  obtained  from  the  diseased  syno- 


*See  "La  dactylite  strumeuse  infantile,"  by  Dr.  Voquet.    "These  de 
Paris,"  1877. 


108  THE   SCROFULOUS   INDIVIDUAL. 

vial  membrane  in  these  cases.*  It  would  appear  that 
in  the  majority  of  these  joint  affections  the  disease  of 
the  synovial  membrane  is  secondary  to  changes  in  the 
articular  ends  of  the  bone. 

Among  the  509  Margate  cases  there  are  143  instan- 
ces of  joint  disease,  which  in  order  of  frequency  are 
thus  localized: — Hip  65,  knee  44,  ankle  14,  elbow  13, 
shoulder  3,  wrist  3,  sacro-iliac  joint  1.  This  "order  of 
frequency  "  exactly  accords  with  that  given  by  Birch- 
Hirschfeld  and  others. 

The  undue  frequency  of  joint  disease  in  individuals 
of  the  male  sex  has  already  been  commented  on. 

The  remaining  affections  to  which  the  scrofulous 
individual  is  liable,  include  such  as  these — scrofulous 
orchitis,  tubercular  or  strumous  affections  of  mucous 
membranes,  such  as  tubercular  cystitis,  "  scrofulous 
tumors  "  of  the  brain,  &c. 

These  latter  diseases  belong  rather  to  the  class  known 
clinically  as  "  tubercular,"  a  term  that  must  be  consid- 
ered as  used  somewhat  in  a  conventional  sense,  and 
more  as  a  matter  of  convenience  than  as  indicative  of 
any  precise  pathological  meaning. 

The  term  senile  scrofula  is  applied  to  instances  where 
familiar  manifestations  of  the  disease  make  their  appear- 
ance in  old  people.     Such  instances  are  rare. 

The  ages  of  the  subjects  of  senile  struma  have 
already  been  alluded  to,  and  it  would  appear  that 
the  disease  is  more  common  in  females  than  among 
men.  In  most  instances  there  is  a  history  of  some 
scrofulous  affection  in  early  life,  the  main  portion 
of  the  patient's  existence  having  been,  however,  abso- 
lutely free  from  any  trace  of  the  disease.  I  might  cite 
as  an  instance  the  case  of  an  old  man,  aged  74,  who 
came  to  the  London  Hospital  with  lupus  erythemato- 
sus of  the  face,  and  extensive  suppurating  gland  masses 
in  the  neck.  He  had  been  perfectly  well  up  to  the 
age  of  70,  but  when  a  lad  he  had  suffered  from  scrofu- 
lous ophthalmia,  his  cornea  still  exhibiting  the  opaci- 


*  Koster  was,  I  believe,  the  first  to  describe  tubercles  in  these  joint 
affections.     See  Virchow's  Archives,  No.  48,  p,  95. 


THE   SCROFULOUS   INDIVIDUAL.  IO9 

ties  of  old  ulceration.  In  this  case  the  patient  had 
been  entirely  exempt  from  any  trace  of  strumous  dis- 
ease for  a  period  of  some  sixty  years.  Often,  however, 
the  disease  would  appear  to  be  primary,  and  such  M. 
Bourdelais  believes  it  to  be  in  the  majority  of  cases.* 
The  diseases  to  which  the  subjects  of  senile  struma  are 
liable  are  identical  with  those  common  in  the  young, 
and  among  them  may  be  mentioned  ulcers  of  the  skin, 
lupus,  glandular  disease,  joint  affections,  and  diseases 
of  bone.  M.  Bourdelais  places  the  last-mentioned  dis- 
eases among  the  most  frequent  manifestations  of  scrof- 
ula in  the  old. 


*  "  Sur  quelques  Observations  de  Scrofule  chez  le  vieillard."  Paris, 
These  No.  297,  1876.  See  also  "  De  quelques  Lesions  tardives  de  Scrof. 
chez  les  vieillards,"  by  Dr.  Du  Moulin,  Paris,  1854;  and  Sir  James 
Paget's  article  already  alluded  to. 


PART   II. 

SCROFULOUS  AFFECTIONS  OF  THE  EXTERNAL 
LYMPHATIC  GLANDS. 


"A  SCROFULOUS  GLAND." 

As  a  preliminary  step  to  this  part  of  the  subject  it  is 
needful  to  explain  in  general  terms  what  is  meant  by  a 
"  scrofulous  gland."  It  is  obvious  that  such  explana- 
tion must  depend  upon  clinical  features,  and  cannot,  of 
necessity,  be  expressed  in  very  precise  terms.  All 
chronically  enlarged  glands  are  not  strumous,  nor  are 
all  gland  enlargements  in  delicate  children  of  a  cer- 
tainty due  to  scrofula.  •  This  may  seem  the  veriest  tru- 
ism and  unworthy  of  mention  were  it  not  for  the  fact 
that  many  writers  appear  possessed  of  the  belief  that 
every  weakly  child  with  an  enlarged  gland  in  its  neck 
must  be  the  subject  of  strumous  disease. 

To  assert  that  a  gland  is  scrofulous  these  conditions 
should  be  present  or  at  least  frequent.  The  patient, 
probably  a  child,  exhibits  some  of  the  general  features 
ascribed  to  the  scrofulous  individual,  or  is  actually  suf- 
fering from  some  recognized  strumous  affection,  or  pre- 
sents such  a  previous  history,  or  such  family  tendencies 
as  have  been  already  described  as  usual  in  scrofula. 
The  gland  tumor  will  be  most  usually  situated  in  the 
neck,  will  have  increased  slowly,  will  have  been  induced 
by  some  trifling  peripheral  lesion,  and  will  have  contin- 
ued to  enlarge  long  after  that  lesion  has  ceased  to  act. 
Moreover,  the  gland  affection  will  spread  in  the  absence 
of  any  fresh  irritation,  the  mass  will  tend  to  become 
caseous,  to  break  down,  and  to  discharge  its  softened 
matter  through  the  skin,  leaving  often  peculiar  sinuses 
or  ulcers,  and  subsequently  peculiar  scars.  The  modi- 
fications of  the  process  are  infinite,  but  such  are  the 
principal  features. 

no 


CHAPTER  X. 

AN   OUTLINE   OF    THE   ANATOMY    OF    THE    EXTERNAL 
LYMPHATIC   GLANDS. 

It  is  needless  to  say  that,  apart  from  any  scientific 
reason,  it  is  essential  to  know  the  situation  of  the 
various  external  lymph  glands,  if  only  for  diagnostic 
purposes. 

Moreover,  the  bulk,  perhaps  all,  of  the  gland  affec- 
tions of  the  strumous  are  secondary  to  some  lesion  or 
irritation  at  the  periphery ;  and  as  the  removal  of  this 
irritation  is  one  of  the  first  and  most  important  ele- 
ments in  treatment,  it  is  more  than  desirable  to  know 
from  whence  the  radicles  of  the  various  glands  are 
derived.  I  will  therefore  merely  state,  in  the  briefest 
psssible  manner,  first,  the  situation  of  the  principal 
glands  of  the  surface  of  the  body ;  and  secondly,  the 
parts  from  whence  their  radicles  or  afferent  vessels  have 
their  origin.  This  description  is  based  almost  entirely 
upon  the  admirable  account  of  the  lymphatic  system 
given  by  Dr.  John  Curnow  in  his  Gulstonian  Lectures 
for  1879.* 

HEAD   AND   NECK. 

The  following  are  the  chief  sets  of  glands: 

1.  The  suboccipital. — One  or  two  glands  situate  in 
the  nape  of  the  neck  about  the  insertion  of  the  corn- 
plexus  muscle.  They  receive  the  lymphatics  from  the 
posterior  part  of  the  scalp. 

2.  The  mastoid. — Four  or  five  small  glands  in  the 
mastoid  region.  They  receive  the  efferent  vessels  from 
tbe  above  set  of  glands,  and  thereby  from  a  portion  of 
the  scalp. 

3.  The  parotid. — Some  five  to  ten  glands  placed  some 
upon  the  surface  and  some  deep  in  the  substance  of  the 

*  Lancet,  vol.  i.  1879,  p.  397  et  seq.  An  exhaustive  account  of  the 
lymphatics  is  given  by  Sappey  in  "  Anat.  phys.  pathol.  des  Vaisseaux 
lymph."   Paris   1871. 

Ill 


112    AN  OUTLINE  OF  THE  ANATOMY  OF  THE 

parotid  gland.  They  receive  lymphatics  from  the 
frontal  and  parietal  regions  of  the  scalp,  from  the  orbit, 
the  posterior  part  of  the  nasal  fossae,  the  upper  jaw, 
and  the  posterior  and  upper  part  of  the  pharnyx. 

4.  The  submaxillary.  —  Twelve  to  fifteen  glands 
arranged  along  the  base  of  the  jaw  under  the  cervical 
fascia.  Receive  lymph  from  the  mouth,  the  lower  lip 
and  gums,  and  possibly  also  from  other  parts. 

5.  The  supra-hyoid. — One  or  two  glands  placed  in  the 
median  line  of  the  neck  between  the  chin  and  the 
hyoid  bone.  Receive  lymph  from  the  chin  and  median 
portion  of  the  lower  lip. 

It  is  important  to  note  that  the  efferent  vessels  from 
all  these  five  groups  of  glands  pass  into  the  deep  cervi- 
cal lymphatic  glands  ;  a  fact  that  considerably  compli- 
cates any  attempt  to  localize  a  peripheral  lesion  in 
many  instances. 

6.  Superficial  cervical. — Some  five  or  more  glands 
that  are  placed  along  the  line  of  the  external  jugular 
vein,  beneath  the  platysma,  but  superficial  to  the 
sterno-mastoid  muscle.  They  receive,  as  afferent  ves- 
sels, lymphatics  from  the  auricle,  from  part  of  the  scalp 
and  skin  of  the  face,  and  from  the  skin  of  the  neck,  and 
some  of  the  efferent  vessels  of  the  mastoid  and  sub- 
maxillary groups  of  glands. 

7.  Deep  cervical,  upper  set. — These  glands,  ten  to  six- 
teen in  number,  are  placed  about  the  bifurcation  of  the 
common  carotid  and  along  the  internal  jugular  vein. 
They  would  be  situated  just  above  the  upper  border  of 
the  thyroid  cartilage,  and  be  also  on  a  level  with  the 
hyoid  bone.  They  receive  lymphatics  from  part  of  the 
tongue,  from  the  palate,  larnyx,  and  lower  part  of 
pharnyx ;  from  the  tonsils,  from  part  of  the  nasal 
fossae,  from  the  deep  muscles  of  the  head  and  neck, 
and  from  within  the  cranium.  Efferent  vessels  from 
the  parotid  and  submaxillary  glands  also  enter  this 
group. 

8.  Deep  cervical,  lower  .s-^.^These  are  situate  in  the 
supra-clavicular  fossae.  They  communicate  with  the 
axillary  glands  by  a  chain  along  the  axillary  artery  and 
brachial  plexus,  also  with  the  glands  of  the  mediasti- 


EXTERNAL   LYMPHATIC   GLANDS.  II3 

num,  with  those  of  the  upper  cervical  set,  and  also  with 
the  sub-hyoid  glands. 

The  cervical  glands  thus  form  a  continuous  series  from 
the  parotid  and  mastoid  groups  above  to  the  subclavian 
and  mediastinal  below. 

9.  Sub-hyoid. — A  few  small  glands  are  placed  below 
the  hyoid  bone  and  above  the  middle  line.  It  is  said 
that  the  string  of  bronchial  glands  may  extend  up  to 
this  set.     (Richet.) 

10.  Retro-pharyngeal. — M.  Gillette  {These  de  Paris, 
1867)  described  two  small  glands  placed  in  front  of  the 
spine  and  upon  the  rectus  capitis  anticus  major  muscle. 
It  is  remarkable  that  into  these  glands  certain  lymph- 
atics of  the  nasal  fossae  enter.  Hence,  as  Fraenkel  * 
has  pointed  out,  "  retro-pharyngeal  abscess  may  arise  in 
consequence  of  disease  of  the  nose." 

It  would  perhaps  be  convenient  to  group  the  rela- 
tions of  certain  glands  to  certain  parts  of  the  periphery 
according  to  regions. 

Scalp. — Posterior  part  =  sub-occipital  and  mastoid 
glands. 

Frontal  and  parietal  portions  =  parotid  glands. 

Vessels  from  the  scalp  also  enter  the  superficial  cer- 
vical set  of  glands. 

Skin  of  face  and  neck  =  for  the  most  part  the  super- 
ficial cervical  glands.  The  lymphatics  of  the  eyelids 
enter  the  parotid  glands.  (See  observation  by  Sir  Wil- 
liam Jenner.f) 

External  ear  =  superficial  cervical  glands. 

Lower  lip  =  submaxillary  and  supra-hyoid  glands. 

Buccal  cavity  =  submaxillary  glands. 

Gums  of  lower  jaw  =  submaxillary  glands. 

Tongue. — Anterior  portion  =  supra-hyoid  glands  and 
those  near  thyroid  cartilage. 

Posterior  portion  =  deep  cervical  glands  (upper  set.) 

Tonsils  =  deep  cervical  glands  (upper  set).  Glands 
about  angle  of  jaw  and  superior  cornu  of  hyoid  bone. 

Palate  =deep  cervical  glands  (upper  set). 

*"  Diseases  of  the  Nose."  Ziemssen's  Cyclopaedia,  vol.  iv.  1877,  p.  187. 
\  Med.   Times  and  Gazette,     vol.  ii.  1861,  p.  423. 

8 


114   AN  OUTLINE  OF  THE  ANATOMY  OF  THE 

Pharynx. — Upper  part  =  parotid  glands  and  retro- 
pharyngeal glands.  Lower  part  =deep  cervical  glands 
(upper  set). 

Larynx  =  deep  cervical  glands  (upper  set). 

Nasal Fossce  =  retro-pharyngeal  glands,  and  some  also 
beneath  upper  part  of  sterno-mastoid.*  Lymphatics 
from  the  posterior  part  enter  the  parotid  glands  in  part 
at  least. 

UPPER  EXTREMITY. 

The  lymphatic  glands  of  the  upper  extremity  are — 

i .  The  Supra-Condyloid  Gland. — This  gland  is  situated 
over  the  internal  intermuscular  septum  of  the  arm,  just 
above  the  inner  condyle  of  the  humerus.  It  receives 
some  superficial  lymphatics  from  the  inner  side  of  the 
forearm,  and  two  or  three  fingers.  Its  efferent  vessels 
pass  up  with  the  basilic  vein  to  enter  the  lower  axillary 
glands. 

The  Axillary  Glands. — These  glands  are  very  num- 
erous, and  are  arranged  in  two  sets  :  (a)  an  internal  set 
placed  along  the  inner  or  thoracic  wall  of  the  axilla, 
and  (b)  an  external  set  ranged  along  the  axillary  vessels 
on  the  outer  aspect  of  the  axillary  space. 

Some  of  the  glands  of  the  internal  set  are  situated 
rather  in  the  base  of  the  axilla,  being  placed  along  the 
course  of  the  long  thoracic  and  subscapular  vessels. 

The  axillary  glands  receive  the  superficial  and  deep 
lymphatics  of  the  upper  limb,  lymphatics  from  the  lum- 
bar and  dorsal  regions,  from  the  posterior  part  of  the 
neck  and  shoulder,  from  the  front  and  sides  of  the 
trunk,  and  from  the  mammary  gland. 

Some  of  the  superficial  lymphatics  of  the  upper  limb 
accompany  the  cephalic  vein,  and  enter  a  gland  just 
below  the  clavicle,  or,  passing  over  that  bone,  join  the 
lower  cervical  glands.  Sometimes  two  or  three  glands 
lie  in  the  course  of  these  vessels  in  the  interval  between 
the  deltoid  and  pectoralis  major  (Curnow).  If  enlarged 
they  may  easily  become  the  subject  of  a  wrong  diag- 
nosis. 

*  For  account  of  lymphatics  of  nose  see  Fraenkel's  monograph,  loc.  cit. , 
p.  126. 


EXTERNAL   LYMPHATIC   GLANDS.  II5 

LOWER  EXTREMITY. 

The  following  are  the  lymphatic  glands  of  this 
part : — 

1.  The  Anterior  Tibial  Gland  (not  constant). — This 
ganglion  is  situated  in  front  of  the  upper  part  of  the 
inter-osseous  membrane.  It  receives  such  deep  lym- 
phatics of  the  leg  as  accompany  the  anterior  tibial 
artery,  and  its  efferent  vessels  enter  the  popliteal 
glands. 

The  Popliteal  Glands. — Usually  about  four  in  number. 
One  is  placed  superficially  just  beneath  the  fascia,  at 
the  point  of  entrance  of  the  short  saphenous  vein.  It 
receives  lymphatic  vessels  that  accompany  that  vein. 

The  remaining  glands  are  deeply  placed  along  the 
popliteal  vessels.  They  receive  such  deep  lymphatics 
of  the  leg  as  accompany  the  posterior  tibial  and  pero- 
neal arteries  ;  and  their  efferent  vessels  pass  up  the  limb 
with  the  femoral  artery,  and  enter  the  deep  set  of  the 
inguinal  glands. 

The  Inguinal  Glands. — These  form  a  numerous  clus- 
ter, and  are  divided  into  a  superficial  and  a  deep  set. 
(a)  The  superficial  set  average  about  ten  glands  in 
number,  although  Curnow  has  counted  twenty  in  this 
situation.  They  are  arranged  in  two  clusters — one 
parallel  and  close  to  Poupart's  ligament,  the  other  par- 
allel and  close  to  the  long  saphenous  vein.  The  former 
cluster,  therefore,  is  almost  horizontal  the  latter 
vertical. 

(b)  The  deep  set — about  four  in  number — are  placed 
along  the  femoral  vein,  and  occupy  the  crural  canal. 

The  inguinal  glands  receive  the  following  lymphatic 
vessels : — 

Superficial  lymphatics  of  lower  extremity.  Enter 
the  vertical  set  of  superficial  glands. 

Superficial  lymphatics  of  lower  half  of  abdomen. 
Enter  the  "  middle  inguinal  "  glands  of  the  superficial 
set  (Curnow). 

Superficial  lymphatics  of  buttock. 

Those  from  the  outer  surface  of  buttock  enter  the 
external  glands  of  the  superficial  set. 


Il6  THE   ETIOLOGY   OF 

Those  from  the  inner  surface  of  buttock  enter  the 
internal  or  vertical  set  of  glands. 

Superficial  lymphatics  of  external'  genitals.  Enter 
the  horizontal  set  of  superficial  glands  ;  some  few  going 
to  the  vertical  set  of  the  same  glands. 

Superficial  lymphatics  of  f>erinaeum.  Enter  the  ver- 
tical set  of  superficial  glands. 

Deep  lymphatics  of  lower  extremity.  Enter  the 
deep  inguinal  glands. 

The  lymphatics  that  accompany  the  obturator, 
gluteal  and  sciatic  arteries,  and  the  deep  lymph  vessels 
of  the  penis,  pass  into  the  pelvis,  and  have  no  concern 
with  the  inguinal  glands. 

The  efferent  vessels  from  the  inguinal  glands  enter 
the  lumbar  set  of  lymphatic  ganglia. 

Curnow  states  that  in  rare  instances  glands  have  been 
found  in  the  following  abnormal  situations: — i.  In 
front  of  the  forearm.  2.  Just  above  the  umbilicus.  3. 
Over  the  seventh  rib ;  and  4,  along  the  inferior  costa  of 
the  scapula. 


CHAPTER  XI. 

THE  ETIOLOGY   OF   SCROFULOUS   LYMPHATIC   GLANDS. 

Exciting  Causes. — All  that  has  been  said  in  the  pre- 
vious chapters  as  to  the  general  etiology  of  scrofula 
applies  of  course  equally  to  this  particular  manifesta- 
tion of  the  disease.  All  that  we  are  concerned  with 
now  is  the  especial  etiology  of  gland  disease,  and  the 
causes  that  actually  incite  or  immediately  induce  that 
affection.  Presume  an  individual  to  be  a  "scrofulous 
subject,"  that  is  to  say,  presume  that  he  has  either 
inherited  or  acquired  a  certain  delicacy  of  health,  a 
certain  tissue  weakness  or  defect,  is  it  possible  for  such 
an  individual  to  spontaneously  develop  grandular  dis- 
ease, or  in  other  words,  is  this  gland  disorder  of  the 
strumous  ever  primary  ?     The  answer  to  this  question 


SCROFULOUS   LYMPHATIC   GLANDS.  llj 

must  certainly  be  in  the  negative,  with  perhaps  some 
very  slight  reservation.  There  is  no  doubt  that  in  the 
great  majority  of  all  strumous  gland  affections  the  mis- 
chief is  secondary,  and  is  dependent  upon  some  pre- 
vious lesion  of  the  periphery,  from  whence  the  lymph 
vessels  going  to  those  glands  are  derived.  This  point 
has  now  for  several  years  been  insisted  on  by  most  of 
those  who  have  treated  the  subject  in  any  way.  In  a 
recent  communication  to  the  International  Medical  Con- 
gress of  1881,*  Dr.  Clifford  Allbutt,  after  asserting  this 
very  generally  allowed  fact,  goes  a  step  further  and  would 
maintain  that  cervical  gland  diseases  "  may  be,  and  often 
are,  set  up  in  young  persons  by  local  causes  alone."  If 
local  causes  alone  are  sufficient  to  induce  scrofulous 
disease,  then  scrofula  may  be  induced  in  any  perfectly 
healthy  and  robust  person,  if  only  the  local  irritation  be 
properly  directed.  So  far  as  one's  present  notions  of 
scrofula  are  concerned  this  would  appear  to  be  a  reductio 
ad  absurdum.  As  the  "  local  causes "  to  which  Dr. 
Allbutt  alludes  are  of  a  very  simple  nature  and  still  more 
frequent  occurrence  ("  irritation  of  the  neighboring 
mucous  membranes  being  the  most  common  "  of  them), 
it  would  appear  that  an  outbreak  of  gland  disease  may 
occurr  in  the  neck  of  any  individual,  however  vigorous ; 
and  it  is  remarkable  that  struma — if  Dr.  Allbutt's  views 
be  true — is  not  an  almost  universal  disease.  While  it 
must  be  allowed  that  in  the  great  mass  of  all  cases  some 
exciting  cause  is  required  to  induce  gland  disease  [a 
tendency  to  scrofulous  disorders  being  already  present), 
it  must  be  confessed  that  in  some  few  instances  no  local 
cause  or  peripheral  lesion  can  be  discovered.  These 
cases,  perhaps  exist  simply  as  an  evidence  of  our  want 
of  knowledge  ;  and  from  what  is  known  of  the  physiology 
and  pathology  of  the  lymphatic  system,  it  is  more  than 
probable  that  in  time  the  etiology  of  these  few  cases 
will  be  placed  upon  the  same  basis  as  the  rest.  The 
cases  that  exhibit  this  absence  of  apparent  local  exciting 
cause  are  very  uniform  in  their  chief  characters.     The 


*"  Abstracts  of  Communications,"  sec.  iv.  p.  106.      "On    the    Origin 
and  Cure  of  Scrofulous  Neck." 


Il8  .      THE   ETIOLOGY   OF 

patients  usually  present  a  distinct  history  of  heredity, 
and  especially  a  tendency  to  phthisis  in  the  family. 
The  gland  disease  increases  very  insidiously,  and  is 
usually  somewhat  wide-spread,  being  most  common  in 
the  axilla  and  base  of  the  neck  ;  or  in  the  groin  also,  in 
addition  to  those  two  situations.  The  gland  masses  do 
not  tend  to  attain  individually  a  great  size,  although 
collectively  they  form  large  tumors  that  often  quite  fill 
up  one  or  both  axillae.  If  operated  upon  the  glands 
shell  out  with  remarkable  ease,  and  exhibit  the  charac- 
ters described  in  class  II.  (see  below);  that  is  to  say, 
they  show  tubercular  structure  in  great  perfection.  I 
have  seen  a  good  number  of  cases  with  features  such  as 
I  have  just  described,  and  in  none  was  there  any  suspi- 
cion of  a  primary  local  lesion.  The  only  references  I  can 
find  to  this  matter  in  books  are  these.  Perrochaud* 
urges  the  existence  of  primary  gland  disease  in  scrofula, 
and  states  that  such  disease  appears  more  often  as  a 
somewhat  general  adenopathy,  affecting  the  neck,  axilla, 
and  groin.  Birch-Hirschfeldf  reports  a  case,  almost 
without  comment,  of  a  lad  aged  four  years  who  had  a 
swelling  of  the  axillary  glands  on  one  side  as  the  sole 
evidence  of  scrofula.  Not  the  least  evidence  of  any 
peripheral  lesion  could  be  found.  His  father,  it  is 
important  to  note,  had  been  a  victim  to  scrofula  in  his 
youth.  The  axillary  tumor  suppurated,  and  then  other 
manifestations  of  scrofula  appeared. 

I  must  repeat  that  these  cases  are  most  probably 
apparent  rather  than  real  exceptions  to  the  general  rule 
that  scrofulous  gland  disease  is  never  primary. 

In  searching  for  peripheral  exciting  lesions  in  any  case 
it  must  be  borne  in  mind  that  these  sources  of  irritation 
are  often  of  the  most  insignificant  nature  ;  and,  more- 
over, the  gland  mischief  may  persist  and  increase  long 
after  all  traces  of  the  exciting  cause  have  disappeared. 

It  is  possible,  for  example,  that  the  enlarged  glands 
in  the  neck  of  a  child  of  10  or  12  might  have  been  due 
to  some  defects  in  the  first  dentition,  to  some  ulceration 


*  Quoted  by  Bourdelais,  "loccit.,"  p.  22. 
f  "  Loc.  cit. ,"  p.  800. 


SCROFULOUS   LYMPHATIC   GLANDS.  II9 

of  the  pharynx  that  had  occurred  years  ago,  and  had 
long  since  healed  up.  As  an  example  of  the  persistence 
of  gland  mischief  after  the  initial  cause  has  ceased  to 
act,  I  might  cite  this  case  from  my  out-patient  depart- 
ment : — 

The  patient,  a  girl  aged  13  years,  had  lost  her  father 
from  phthisis,  and  had  brothers  and  sisters  who  were 
afflicted  with  scrofula.  The  child  was  perfectly  free 
from  any  trace  of  strumous  disease  until  she  was  8  years 
of  age.  She  then  accidentally  ran  a  fork  into  her  chin. 
The  wound  suppurated,  and  enlarged  glands  began  to 
appear  in  the  supra-hyoid  region  close  to  the  puncture. 
In  about  three  weeks  the  wound  had  perfectly  healed, 
but  the  gland  disease  gradually  increased  and  spread, 
until  now  she  has  large  tumors  in  both  sides  of  the  neck, 
the  glands  in  the  supra-hyoid  region  having  also  suppu- 
rated and  led  to  sinuses.  There  was  a  total  absence  of 
any  other  peripheral  injury. 

Here  it  would  appear  that  gland  disease  was  active 
five  years  after  the  lesion  that  first  excited  it  had  ceased 
to  act. 

Another  point  to  remember  in  inquiries  upon  this 
subject — especially  where  the  neck  and  axillae  are  con- 
cerned— is  that  external  gland  disease  may  be  set  up 
by,  or  may  extend  from  disease  in  the  interior  of  the 
body.  The  cases  of  Drs.  Hilton  Fagge  and  Goodhart, 
already  alluded  to,  illustrate  this  point,  and  show 
the  extension  of  gland  disease  from  the  chest  into 
the  neck.  In  like  manner,  one  knows  that  in  phthisis 
the  glands  about  the  clavicle  and  also  in  the  axilla  may 
become  enlarged.  Through  the  kindness  of  my  col- 
league Mr.  McCarthy  I  had  recently  an  opportunity  of 
examining  some  gland  masses  that  had  been  removed 
from  the  axilla  of  a  woman  suffering  from  phthisis. 
These  gland  tumors,  which  were  very  extensive,  exhi- 
bited the  precise  characters  of  scrofulous  glands.  I  have 
notes  of  two  or  three  casses,  where  the  gland  mischief 
in  the  neck  had  evidently  extended  from  like  trouble  in 
the  mediastinum  or  about  the  bronchi,  although,  had 
the  cervical  disease  not  appeared,  the  gland  affections 
in  the  latter  situations  would  not  have  been  suspected. 


120  THE   ETIOLOGY   OF 

We  might  now  consider  the  actual  local  lesions  them- 
selves that  induce  gla?id  disease. 

Enlargement  of  the  bronchial  glands  is  usually  sub- 
sequent to  bronchitis,  especially  the  bronchial  catarrh 
associated  with  measles.  It  may  also  follow  upon  whoop- 
ing cough,  and  probably  upon  most  lung  affections.  The 
mesenteric  gland  disease  is  directly  caused  by  some 
catarrh  (scrofulous  catarrh)  of  the  intestine,  or  by  some 
graver  lesion,  such  as  ulceratien  of  the  mucous  lining 
of  the  gut.  It  is  seldom  in  post-mortems  on  scrofulous 
children  over  a  certain  age  that  one  omits  to  find  some 
enlargement  of  the  mesenteric  glands.  The  frequency 
of  their  occurrence  would  probably  coincide  with  the 
frequency  of  those  digestive  disturbances  that  are  so 
common  in  the  strumous,  although  on  the  point  of  fre- 
quency few  would  be  enclined  to  endorse  the  assertion 
of  Wiseman  that  "  whenever  the  outward  glands  do 
appear  swelled  you  may  safely  conclude  the  mesenteric 
to  be  so  too,  they  being  usually  the  first  part  that  is 
attacked  by  the  malady."  * 

The  peripheral  disturbances  that  may  induce  gland 
disease  in  the  neck  are  very  numerous.  Among  them 
may  be  mentioned — eruptions  of  the  head  and  face, 
especially  porrigo  of  the  scalp,  ulcers  of  the  skin,  all 
forms  of  stomatitis,  thrush,  inflammatory  affections  of 
the  gums  or  tongue,  catarrh  and  ulceration  of  the 
pharynx,  affections  of  the  tonsils,  coryza,  ozcena,  or 
other  disorders  of  the  nose,  diseases  of  the  external  and 
internal  ear,  imperfect  dentition,  and  decay  of  the  first 
set  of  teeth.  Of  the  comparative  potency  of  some  of 
these  lesions  of  the  surface  I  shall  speak  presently. 

The  great  tendency  for  naso-pharyngeal  catarrhs  to 
produce  gland  enlargement  can  to  a  great  extent  explain 
the  frequency  of  such  enlargements  after  measles  and 
scarlet  fever.  So  constantly  do  we  hear  parents  ascrib- 
ing the  scrofula  in  their  children  to  an  attack  of  measles 
that  one  would  be  disposed  to  doubt  if  a  child  with  a 
scrofulous  tendency  could  have  measles  and  escape 
strumous  gland  disease,  were    there  not    instances  to 

*  Richard  Wiseman.     "  Chirurgical  Treaties."     London,  1692. 


SCROFULOUS   LYMPHATIC   GLANDS.  121 

prove  the  fallacy  of  such  a  suggestion.  In  considering 
the  disposition  of  measles  to  induce  scrofulous  manifes- 
tations, it  must  be  borne  in  miud  that  this  fever  is  one 
of  the  earliest  ailments  of  children,  that  it  furnishes 
perhaps  the  first  opportunity  that  has  been  afforded  of 
detecting  any  flaw  in  the  child's  state  of  health,  and 
that  it  occurs,  moreover,  at  a  time  when  gland  disease 
is  *naturally  prone  to  appear.  Gland  tumors  in  the 
axilla,  bend  of  elbow,  groin,  and  //«;«,  may  be  locally 
induced  by  various  forms  of  peripheral  mischief,  such  as 
eruptions,  ulcers,  broken  chilblains,  suppurative  bone 
and  joint  affections,  abscesses,  etc. 

So  far  the  local  affections  that  have  been  credited  as 
causes  of  strumous  adenopathy  have  been  for  the  most 
part  inflammatory ;  there  remains  to  be  considered  the 
i/ifluence  of  injury  and  of  cold,  and  the  question  of  sud- 
den gland  enlargement. 

Injury  by  inducing  inflammatory  changes  may  of 
course  set  up  gland  mischief,  as  in  the  case  just 
reported,  where  a  child  was  wounded  in  the  chin  with 
a  fork  ;  and  examples  of  like  nature  are  not  uncommon. 
I  have  notes  of  a  case,  however,  where  I  think  the  gland 
mischief  was  set  up  by  an  actual  contusion  of  the  gland 
itself.  In  this  instance  the  child  was  struck  across  the 
side  of  the  neck  by  a  falling  case,  a  swelling  ensued, 
and  on  its  subsidence  an  enlarged  and  tender  gland  was 
apparent.  The  disease  subsequently  spread  in  a  leis- 
urely manner.  Price  *  asserts  that  sprains  and  other 
injuries  may  lead  to  primary  enlargement  of  the  axil- 
lary glands,  but  he  adds  nothing  to  the  bare  assertion. 

Cold. — Dr.  Reid  observes,  "  I  have  seen  the  glands 
on  one  side  of  the  peck  and  throat  swelled  and  inflamed 
by  a  momentary  blast  of  cold  air."  Other  authors  cite 
like  cases,  and  many  assign  cold  and  exposure  as  direct 
exciting  causes  of  strumous  glands.  I  very  much  doubt 
if  cold  or  exposure  have  ever  directly  induced  a  scrofu- 
lous gland.  I  can  quite  believe  that  such  glands  may 
follow  upon  exposure,  but  in  such  instances  I  imagine 


*  "On  Scrofulous  Diseases  of  the  External  Lymphatic  Glands."     By 
P.  C.  Price.     London,  1861,  p.  61. 


122  THE   ETIOLOGY   OF 

that  the  lymphatic  mischief  is  due  to  a  catarrh  of  the 
throat  or  nose  set  up  by  cold  or  damp.  It  is  well 
known  how  rapidly  the  cervical  glands  will  often  enlarge 
in  a  case  of  common  sore  throat. 

I  venture  to  doubt  the  reality  of  all  the  reported 
cases  of  so-called  sudden  enlargement.  As  an  instance, 
I  might  quote  the  example  furnished  by  Wiseman.* 
Says  he : — 

"  I  shall  give  you  a  remarkable  instance  of  a  cook's 
servant  in  the  Old  Bailey  who,  sleeping  one  summer 
night  upon  a  form,  his  head  slipping  off  the  one  side 
of  this,  his  neck  pressed  upon  the  end  of  it.  When  he 
awakened  his  neck  was  full  of  struma  on  both  sides, 
some  as  big  as  walnuts,  others  less.  They  were  of  dif- 
ferent figures,  and  distinct  one  from  another.  He  was 
frequently  let  blood  and  purged.  All*  else  was  done 
that  expert  physicians  and  chirurgeons  thought  fit  to 
relieve  him,  but  the  struma  continued,  and  after  a  few 
days  mattered,  and  became  virulent  ulcers.  He  died 
tabid  within  half  a  year." 

One  knows  how  long  gland  disease  may  remain  dor- 
mant before  it  is  perceived  by  the  patient,  and  how 
often  such  discovery  is  accidental.  In  this  case  of 
Wiseman's  and  in  like  instances  I  should  imagine  that 
that  the  pain  in  the  neck  induced  by  an  uncomfortable 
position  drew  the  man's  attention  to  the  existence  of 
the  disease,  which  had  been  of  previous  standing.  It 
is  remarkable,  in  the  present  instance,  that  the  "strumae" 
appeared  in  both  sides  of  the  neck,  and  not  only  in  the 
side  injured  or  compressed. 

Details  as  to  age  and  sex — such  as  they  are — have 
been  given  previously. 

Situation  of  gland  disease. — Taking  into  consideration 
the  whole  lymphatic  system,  the  glands  that  are  most 
frequently  the  seat  of  strumous  disease  are  the  cervical, 
the.  bronchial,  and  the  mesenteric. 

Considering  only  the  external  glands,  an  analysis 
of  the  Margate  cases  gives  the  following  results.  Out 
of  a  total  of  509  cases  of  scrofula  there  were  155   ex- 

*  "  Loc.  cit.,"  No.  4.  p.  400. 


SCROFULOUS   LYMPHATIC   GLANDS. 


123 


amples  of  gland  enlargement.     These  were   thus   dis- 
tributed : 


Neck  alone 
Neck  and  axilla 
Groin  alone 
Axilla  alone 
Neck  and  groin 
Neck,  groin,  axilla 


131 

12 

6 

4 
1 
1 


155 
These  figures  show  the  immense  preponderancy  of 
cervical  adenopathy.  They  also  show  that  the  axillary 
glands  are  seldom  affected  unless  those  of  the  neck  are 
also  involved,  and  that  gland  disease  in  two  remote 
regions  (as,  for  example,  the  neck  and  groin)  very  rarely 
occur  at  one  and  the  same  time. 

The  nature  of  the  peripheral  lesion  that  induces  gland 
disease. — So  far  as  I  am  aware  no  satisfactory  answer 
has  as  yet  been  given  to  the  question — Why,  of  all 
other  external  glands,  are  those  in  the  cervical  region 
so  often  the  seat  of  strumous  disease  ?  Many  explana- 
tions have  been  offered.  It  has  been  said  that  the  face 
and  neck  being  uncovered  are  more  exposed  to  such 
external  influences  as  cold  and  damp.  It  has  been  said 
that  the  peripheral  lesions  that  lead  to  scrofulous  dis- 
ease are  more  frequent  about  the  head  and  neck  than 
they  are  elsewhere.  It  has  been  said  that  the  glands 
in  the  cervical  region  are  more  numerous  than  they  are 
in  the  groin,  axilla,  ham,  and  bend  of  elbow.  These 
explanations,  I  would  hold,  are  not  valid.  Are  not  the 
limbs,  the  hands,  and  feet,  subject  to  a  vast  number  of 
inflammatory  affections  akin,  at  least,  to  those  about 
the  head  and  face  ?  Ulcers  are  not  uncommon  upon 
the  extremities  of  the  scrofulous,  the  fingers  and  toes 
are  often  the  seat  of  ulcerating  chilblains,  that  remain 
inflamed  for  months,  the  feet  and  hands  are  by  no 
means  rarely  exposed  to  wet  and  cold  (if  it  be  insisted 
that  these  agents  have  any  direct  action  at  all),  and 
injuries,  such  as  wounds,  scratches,  and  abrasions  are,  I 
presume,  more  common  about  children's  limbs   than 


124  THE   ETIOLOGY   OF 

they  are  about  their  heads  and  faces.  Even  allowing 
that  peripheral  lesions  are  more  common  about  the 
radicles  of  the  neck  glands  than  they  are  elsewhere,  is 
their  number  so  greatly  in  excess  of  those  that  can 
affect  the  axillary  glands  that  the  proportion  can  be 
expressed  by  the  figures  131  to  4?  I  should  imagine 
not.  With  regard  also  to  the  comparative  numbers  of 
glands  in  different  parts,  it  might  be  acknowledged  (no 
doubt  correctly)  that  the  cervical  glands  outnumber  the 
axillary.  But  is  this  disproportion  as  131  to  4  ?  As  a 
matter  of  fact  some  of  the  most  extensive  and  most 
numerous  gland  masses  met  with  have  been  turned  out 
of  the  axilla,  and  there  are  many  reasons  for  knowing 
that  the  glands  in  the  neck  are  in  no  very  great  excess 
of  those  in  the  armpit.  If  frequent  movement  be  con- 
sidered to  offer  encouragement  to  the  development  of 
buboes  in  any  part,  then  I  think  that  the  axilla  and  the 
groin  would  be  less  frequently  at  rest  than  is  the  neck. 
Lastly,  I  believe  it  will  be  acknowledged  that  the 
glands  in  the  axillae  and  inguinal  regions  are  more  often 
affected  in  the  non-strumous  than  are  the  glands  in  the 
neck. 

The  explanation  I  would  offer  of  this  discrepancy  is 
the  following : — The  peripheral  lesions  most  active  in 
exciting  gland  disease  in  scrofula  are  those  that  are 
located  in  the  adenoid  tissue  of  a  mucous  membrane. 
Adenoid  or  lymphoid  tissue  is  to  be  found  in  the  sub- 
mucous tissue  of  most  mucous  membranes.  But  it 
varies  greatly  in  amount  in  different  parts.  It  is  par- 
ticularly collected  about  the  mouth  and  pharynx,  form- 
ing in  the  latter  situation  the  largest  masses  of  adenoid 
tissue  in  the  body,  viz.,  the  tonsils.  A  vast  quantity  is 
also  distributed  over  the  posterior  wall  of  the  pharynx. 
It  is  plentiful  in  the  bronchial  mucous  lining,  and  also 
in  the  intestines,  where  it  appears  as  those  special  col- 
lections,'the  solitary  glands  and  Peyer's  patches,  and 
has  besides  a  very  extensive  distribution. 

Now  the  most  common  sets  of  glands  in  the  body 
to  be  the  seats  of  scrofulosis  are  the  cervical  glands, 
the  bronchial  glands,  the  mesenteric  glands ;  and  it  is 
at  least  significant  that  these  organs  correspond  to  the 


SCROFULOUS   LYMPHATIC    GLANDS.  1 25 

most  extensive  collections  of  adenoid  tissue  in  the 
body,  viz.,  those  situated  in  the  naso-pharyngeal 
mucous  membrane,  the  lining  of  the  bronchi,  and  the 
inner  coat  of  the  intestine.  Entering  more  into  detail, 
I  should  say  that  the  commonest  causes  of  cervical 
gland  disease  are  situate  in  the  pharynx,  and  especially 
in  the  tonsil.  In  non-strumous  cases,  one  cannot  fail  to 
be  struck  with  the  extraordinary  rapidity  with  which 
the  glands  are  involved  in  inflammatory  affections  of 
the  throat  and  tonsil.  Indeed,  one  of  the  earliest  evi- 
dences of  such  affections  is  often  a  tender  and  then  a 
swollen  condition  of  the  glands  about  the  hyoid  bone. 
Compare  these  throat  affections  with  an  eruption  on 
the  scalp  or  an  ulcer  of  the  face — where  no  adenoid 
tissue  exists — and  note  the  tardy  manner  in  which  the 
glands  are  implicated.  I  have  observed  the  glands 
unenlarged  in  instances  where  a  sore  upon  the  cheek  or 
an  eczema  of  the  head  has  existed  for  weeks,  and  that, 
moreover,  in  a  scrofulous  child.  One  has  sometimes 
an  opportunity  of  comparing  the  effect  of  lesions  in  dif- 
ferent sites  upon  the  gland  apparatus  in  the  same 
patient.  Such  an  instance  is  the  following: — A  little 
girl,  aged  six,  a  member  of  a  strumous  family,  had  a 
scrofulous  ulcer  upon  the  cheek  that  had  existed  for 
nearly  a  month,  and  yet  the  corresponding  glands  were 
not  enlarged.  She  then  became  the  subject  of  an 
ulcerative  pharyngitis  (2°,  e.,  adenoid  tissue  became 
involved),  and  in  a  few  days  the  glands  on  both  sides  of 
the  neck  were  enlarged,  and  subsequently  attained  con- 
siderable proportions. 

To  make  other  comparisons.  There  is  adenoid  tissue 
in  the  nose,  about  the  mouths,  under  the  conjunctiva. 
There  is  none  in  the  limbs.  Note,  then,  how  readily 
the  neck  glands  become  involved  in  strumous  ophthal- 
mia, in  ozcena,  in  sores  about  the  gums  or  tongue; 
and,  on  the  other  hand,  observe  how  long  a  time  may 
elapse  before  the  axillary  glands  are  implicated  in  a 
case  of  ulcer  of  the  forearm,  or  in  a  case  of  dactylitis, 
or  a  case  of  suppurative  mischief  in  a  joint.  How 
trifling  very  often  is  the  gland  enlargement  in  such  instan- 
ces.    Moreover,  this  proness  for  adenoid  tissue  is  quite 


126  THE   PATHOLOGY   OF 

in  accord  with  what  we  know  of  the  tendencies  of 
scrofula,  and  especially  of  its  disposition  to  involve 
lymphatic  structures,  and  is  quite  in  agreement  with 
the  definition  proposed  for  the  disease. 

Putting  aside  this  matter  of  lymphoid  tissue  there  are 
some  few  other  differences  in  the  power  of  peripheral 
lesions  to  excite  strumous  adenopathy.  It  may  be 
unnecessary  to  observe  that  a  suppurative  inflammation 
of  the  surface  is  more  prone  to  involve  glands  than  is  a 
non-pustular  affection ;  that  an  ulcer  of  the  forearm  is 
more  potent  than  is  a  simple  eczema  in  the  same  situa- 
tion. These  differences  depend  mainly  of  course  upon 
the  detail  of  time  and  the  depth  of  tissue  involved. 
Retained  pus  is  an  extremely  potent  cause  of  gland 
enlargement.  For  example,  a  porrigo  of  the  scalp, 
where  the  scabs  are  allowed  to  remain  and  the  pus  to 
be  pent  up  beneath  them,  is  much  more  active  than  is 
a  like  disease  kept  free  from  scab  formation.  And  this 
discrepancy  has  often  appeared  to  me  to  exist  indepen- 
dent of  the  extent  of  surface  involved,  the  duration  of. 
the  disease,  and  the  depth  to  which  it  has  extended. 

Lastly,  it  must  be  remembered  that  individual  idio- 
syncrasy has  a  great  deal  to  do  with  the  readiness  or 
tardiness  with  which  gland  disease  occurs  after  like 
provoking  causes,  and  into  this  matter  the  bar  of  almost 
utter  ignorance  at  present  prevents  us  from  entering. 


CHAPTER  XII. 

THE  PATHOLOGY  OF  SCROFULOUS   LYMPHATIC 
GLANDS. 

I  propose  to  detail  in  this  chapter  the  pathological 
changes  that  occur  in  strumous  glands,  and  to  give  an 
account  of  the  appearances  they  offer  under  the  micro- 
scope. 

The  appearances  presented  by  these  diseased  glands 


SCROFULOUS   LYMPHATIC   GLANDS.  127 

vary  greatly,  not  only  when  viewed  with  the  naked  eye, 
but  also  when  subjected  to  a  microscopic  examination. 
But  in  spite  of  the  many  diversities  in  aspect  that 
exist  it  must  be  borne  in  mind  that  the  process  that 
underlies  them  all  is  one  and  the  same,  and  that 
throughout  the  whole  series  of  scrofulous  gland  affec- 
tions we  have  to  deal  only  with  the  outcomes  of  that 
peculiar  inflammation  I  have  already  described,  an 
inflammation  that  numbers  among  its  products  elements 
so  remarkable  as  giant  cells  and  tubercles.  It  matters 
not  whether  the  process  concerned  in  this  disease  be 
called  the  scrofulous  process  or  the  tubercular  process, 
so  long  as  the  fact  is  recognized  that  there  is  but  one 
morbid  change  underlying  the  many  aspects  of  the  dis- 
order, and  that  the  apparent  diversities  indicate  differ- 
ences in  degree  rather  than  in  kind. 

I  would  venture  to  particularly  insist  upon  this  point 
in  respectful  opposition  to  the  views  of  those  who  have 
maintained  that  several  distinct  pathological  processes 
are  concerned  in  strumous  gland  disease.  By  many 
these  tumors  have  been  divided  into  those  that  are  due 
to  simple  chronic  inflammation,  those  that  depend  upon 
a  simple  hypertrophy,  and  those  that  have  been 
occasioned  by  a  deposit  of  tubercle.  Here  three  dis- 
tinct morbid  changes  are  credited  with  a  capacity  for 
producing  the  same  diseased  tissue — a  strumous  gland. 
If  simple  chronic  inflammation  can  be  the  sole  factor 
in  scrofula,  then  the  indolent  bubo  that  may  form  in 
the  groin  of  a  healthy  lad  from  an  abrasion  on  the  foot 
may  be  reckoned  as  scrofulous.  With  regard  to  hyper- 
trophy, the  conditions  that  are  allowed  to  be  active  in 
producing  hypertrophy  elsewhere  are,  I  think,  not  to 
found  about  strumous  glands.  The  process  would 
appear  rather  to  be  an  irritative  one  ;  and  if  it  be  true 
that  lymph  glands  accurately  reproduce  the  features  of 
disturbing  lesions  at  the  periphery,  and  those  lesions  be 
allowed  to  be  inflammatory,  it  would  seem  that  there  is 
little  need  of  invoking  the  aid  of  hypertrophy.  More- 
over, the  description  given  of  these  hypertrophied 
bodies  is  that  of  a  well-recognized  variety  of  gland 
tumor  that  shows  under  the  microscope  changes  very 


128  THE   PATHOLOGY   OF 

different  from  those  of  hypertrophy.  I  think,  more- 
over that  the  glands  described  by  Sir  William  Jenner* 
as  being  the  seat  of  "  albuminoid  infiltration,"  do  not 
merit  the  special  character  he  ascribes  to  them.  The 
account  he  gives  of  the  aspect  of  such  glands  shows 
that  they  are  absolutely  identical,  in  aspect  at  least, 
with  an  indolent  gland  enlargement  in  struma  that 
shows  the  microscopic  changes  incident  to  scrofula,  and 
affords  no  evidence  of  any  peculiar  infiltration. 

In  detailing  the  minute  changes  observed  in  this  affec- 
tion, I  propose  to  divide  scrofulous  gland  tumors  into 
two  classes.  There  is  no  object  for  this  division  other 
than  that  of  a  greater  convenience  for  description.  The 
two  classes  represent  but  grades  or  degrees  of  one  and 
the  same  morbid  process.  In  actual  fact  they  are  sep- 
arated by  no  rigid  line  of  demarcation,  but  merge 
imperceptibly  the  one  into  the  other,  and  the  division 
I  have  placed  between  them  is  therefore  purely  arbi- 
trary. In  the  first  division  will  be  described  the  changes 
occurring  in  those  glands  that  exhibit  the  process  in  its 
more  active  or  intense  forms,  and  in  the  second  division 
those  enlargements  that  show  the  more  indolent  change, 
and  that  are  in  a  sense  the  more  chronic. 

f  The  first  change  noticed  in  scrofulous  glands  is 
an  increase  in  the  number  of  their  lymph-corpuscles,  an 
increase  observed  both  in  the  sinuses  of  the  organ,  and 
in  the  proper  gland-tissue  itself.  The  more  active  the 
process  the  better  marked  is  the  change,  the  sinuses  in 
such  cases  appearing  so  blocked  and  crowded  with 
lymphoid  bodies,  that  Berlin  blue  injected  by  a  Pra-. 
vaz's  syringe  only  imperfectly  follows  the  course  of  the 
lymph-paths. 

It  is  significant  to  observe,  that  an  increase  in  the 
number  of  their  contained  corpuscles  is  the  very  first 
indication  of  the  inflammatory  process  as  it  effects 
lymphatic  vessels,  a  condition  constantly  observed  by 

*Article  on  "  Rickets."  Medical  Times  and  Gazette,  vol.  i.  1861,  p.  260. 

f  The  account  that  follows  of  the  histology  of  these  glands  is  in  the 
main  a  reprint  of  that  given  in  a  lecture  I  delivered  at  the  Royal  College 
of  Surgeons  in  March  1881,  and  that  was  published  shortly  after  in  the 
"  British  Medical  Journal." 


SCROFULOUS   LYMPHATIC   GLANDS.  1 29 

Dr.  Klein  in  the  pleural  lymphatics  of  animals,  the  sub- 
jects of  chronic  pleurisy.  And  in  connection  with  this 
point  it  is  necessary  to  remember  that  the  mode  of 
development  of  lymphatic  gland  masses  shows  that  they 
are  merely  modified  lymphatic  vessels.  Whence  these 
corpuscles  come  it  is  perhaps  at  present  impossible  to 
say,  but  it  has  been  suggested,  with  reference  to  this 
condition  both  in  the  glands  and  in  the  vessels,  that 
they  may  have  been  derived  from  some  initial  seat  of 
inflammation,  or  that  they  are  leucocytes  escaped  from 
the  neighboring  blood-vessels,  or  finally,  that  they  owe 
their  origin  to  the  proliferation  of  the  existing  cells  of 
the  part.  And  it  may  here  be  convenient  to  allude  to 
a  singular  and  incorrect  statement  that  appears  to  have 
been  handed  down  from  one  pathological  handbook  to 
another ;  and  that  is,  to  the  effect  that  the  changes  in 
the  glands  are  first  observed  at  their  extreme  periphery, 
i.  e.  in  the  cortical  sinuses  and  follicles,  a  statement 
explained  by  the  theory  that  the  periphery  is  that  part 
of  the  gland  that  would  be  first  exposed  to  any  irritant 
brought  from  a  primary  seat  of  inflammation.  With 
reference  to  this  statement,  I  must  assert  that  in  no 
single  instance,  in  all  the  specimens  examined,  have  I 
ever  found  the  morbid  changes  commencing  at  the 
periphery  of  the  organ,  including  in  that  term  the  cor- 
tical sinuses,  and  a  fair  amount  of  the  cortical  follicles. 
Indeed,  the  exact  converse  holds  goods,  and  the  changes 
invariably  commence  in  the  medullary  or  deeper  por- 
tions of  the  gland.  It  must  have  been  obvious,  over 
and  over  again,  to  all  who  have  cut  open  a  scrofulous 
gland,  that  the  gross  changes  visible  to  the  eye  are 
always  most  advanced  in  the  central  parts  of  the  organ. 
If  there  be  only  a  few  specks  of  caseous  change  visible, 
they  will  always  be«  found  to  occupy,  not  of  necessity 
the  precise  centre  of  the  affected  organ,  but,  at  least, 
a  part  other  than  the  extreme  periphery.  The  same 
holds  good  for  limited  suppuration,  and,  within  cer- 
tain limits,  for  even  extensive  purulent  or  caseous  col- 
lections. 

I  have  a  section  cut  from  a  large  gland  of  more  than 
one  inch  in  diameter  that  was  absolutely  caseous  through- 
9 


130  THE   PATHOLOGY   OF 

out,  with  the  sole  exception  of  the  extreme  periphery, 
where  unaltered  lymph-corpuscles  can  still  be  seen  in 
great  numbers.  If,  however,  the  previous  statement 
were  true,  and  the  changes  commenced  in  the  periphery, 
one  would  expect  to  find  them  most  advanced  in  that  sit- 
uation. So  much  for  the  fact.  With  regard  to  the  theory, 
notice  has  not  apparently  been  taken  of  this  fact,  that 
the  afferent  vessels  of  the  gland  first  enter  the  plexus 
between  the  strata  of  the  capsule,  and  then  pass  on  to 
the  cortical  sinuses.  The  capsular  plexus,  therefore,  is 
the  part  of  the  gland  first  brought  into  contact  with 
infecting  material,  and  yet  the  capsule  is  acknowledged 
by  these  very  observers  to  be  only  secondarily  affected  ; 
aad,  as  a  matter  of  fact,  this  plexus  is  almost  the  last 
part  of  the  true  gland-tissue  to  be  involved. 

The  next  change  noticed  in  these  glands  assumes  the 
form  of  certain  spots  of  varying  size  and  shape,  and 
which  owe  their  conspicuousness  to  the  fact  that,  in 
specimens  prepared  with  haematoxylin,  they  appear 
more  lightly  stained  than  does  the  rest  of  the  gland. 
They  are  observed  first  in  the  medulla,  then  in  the  cor* 
tex,  and  are  always  limited  to  the  gland  tissue  proper. 
The  more  active  the  process  the  more  diffused  is  the 
change,  and  the  appearance  of  distinct  spots  or  foci  of 
altered  tissue  is  best  seen  in  glands  that  do  not  exhibit 
the  most  vigorous  aspect  of  the  disease. 

Closer  examination  shows  that  these  districts  are 
occupied  by  a  large  number  of  cellular  forms  of  very 
diverse  character;  they  range  from  ordinary  lymph- 
corpuscles  on  the  one  hand,  to  certain  very  large  and 
conspicuous  cell  elements  on  the  other.  These  latter 
are  nucleus-like  roundish  bodies,  that  stain  lightly, 
are  pellucid,  and  present  a  very  distinct  intranuclear 
plexus ;  between  them  and  the  unaltered  lymph-cor- 
puscles every  gradation  can  be  observed,  and  there  can 
be  no  doubt  that  from  these  latter  they  are  derived. 
All  these  elements,  both  large  and  small,  show  evidence 
of  active  division.  The  endothelial  cells  of  the  part 
appear  unaltered.  The  blood-capillaries  in  these  dis- 
tricts are  very  numerous  and  distinct,  and  are  often  pro- 
vided with  a  well-marked  adenoid  sheath  that,  while 


SCROFULOUS  LYMPHATIC  GLANDS.  131 

described  by  His  as  of  normal  occurrence,  is  certainly 
best  seen  in  slightly  inflamed  glands.  That  these  con- 
spicuous changes  indicate  so  many  spots  or  foci  of 
inflammation  may,  I  presume,"  be  granted,  especially 
on  the  ground  of  their  precise  resemblance  to  changes 
elsewhere  of  undoubted  inflammatory  origin. 

The  large  cells  with  glistening  protoplasm  form  a 
great  feature  in  all  scrofulous  inflammation.  They 
were  first  noticed  by  Rindfleisch,  who  regarded  them 
as  characteristic  ;  he  described  their  segmentation,  and 
conceived  their  origin  to  be  from  the  leucocytes  of 
the  part,  an  origin  almost  undoubted  in  the  present 
instance.  All  subsequent  pathologists  have  observed 
them,  and  their  almost  uniform  appearance  in  scroful- 
ous inflammation  is  an  important  factor  in  that  process. 
With  regard  to  the  future  of  the  cell-products  in 
these  exudations,  it  can  only  be  said  that,  as  a  whole, 
they  are  short  lived,  or  become  involved  in  subsequent 
changes.  The  large  elements,  especially,  soon  undergo 
degeneration  and  disappear  from  the  scene ;  in  no 
instance  do  they  experience  any  further  development, 
and  they  have  no  share  whatsoever  in  the  formation 
of  giant-cells,  which,  it  may  be  remarked,  are  never  ob- 
served at  this  stage  of  the  process.  The  changes 
indicated  become  more  or  less  general,  and  very  soon 
fresh  manifestations  of  a  somewhat  different  character 
become  apparent. 

These  concern  the  lymph  sinuses  of  the  part  engag- 
ing first  those  situate  towards  the  medulla.  The  endo- 
thelial cells  that  line  these  passages  show  evidence  both 
of  individual  and  of  the  numerical  increase,  and  become 
very  distinct.  At  the  same  time  the  fine  reticulum 
that  normally  occupies  the  lumen  of  the  sinus  becomes 
considerably  augmented  by  the  development  of  fresh 
fibres  and  bands  that  stretch  across  the  passage,  and 
help  to  more  fully  occupy  it.  The  fibres  of  this  new 
reticulum  are  soft  and  less  fine  than  is  the  normal  tis- 
sue, and  some  of  the  bands  that  stretch  across  the  sinus 
are  rather  membrane-like  expansions.  This  reticulum 
is  closely  associated  with  the  lining  endothelial  cells, 
and  from  them  it  is  probably  developed. 


132  THE   PATHOLOGY  OF 

This  change  is  very  similar  to  that  observed  by 
Klein  in  the  lymphatic  vessels  under  the  pleura,  and  in 
the  lungs  in  cases  of  chronic  pleuritis.  Within  the 
lymphatics  in  this  inflammation  he  describes  a  reticu- 
lum as  being  developed,  and  to  which  he  has  given  the 
name  of  the  "  endo-lymphangeal  network."  * 

Within  these  altered  sinuses  are  a  number  of  leucocy- 
tes, some  normal  of  aspect,  others  exhibiting  the 
changes  already  described,  and  a  small  proportion  of 
the  large  cell  elements  of  Rindfieisch.  Other  tubes  or 
passages  become  apparent  in  glands  the  seat  of  strum- 
ous dsease,  that  I  have  ventured  to  describe  as  lym- 
phatic vessels  proper  to  the  gland  tissue.f  They  also 
develop  across  their  lumen  a  fine  reticulum,  and  show 
changes  identical  with  those  exhibited  by  the  sinuses. 

Marked  changes  at  the  same  time  are  going  on  in 
the  gland-tissue,  adjacent  to  these  affected  vessels  and 
sinuses.  That  tissue,  already  crowded  with  altered 
lymph-corpuscles  and  the  typical  large-cell  elements,  be- 
comes conspicuous  by  the  appearance  of  opacity,  and  the 
loss  of  the  transparent  condition  of  the  intercellular  spa- 
ces. This  opacity  is  always  first  noticed  in  the  immediate 
vicinity  of  the  sinuses  or  vessels,  and  is  due  to  deposit 
in  the  part  of  a  homogeneous  material  that  is  obviously 
only  coagulated  lymph.  The  corpuscles  appear  embed- 
ded in  this  material,  and  the  anatomical  details  of  the 
affected  district  become  indistinct.  The  fibres  of  the 
adenoid  reticulum  increase  in  density  and  width, 
become  softened,  and  of  so  nearly  the  same  refractive 
index  as  the  structureless  coagulum,  that  the  general 
ground-substance  of  the  spot  assumes  a  more  or  less 
homogeneous  appearance.  These  spots  tend  to  entend 
by  peripheral  increase,  and  always  assume,  therefore,  a 
rounded  outline;  for  the  same  reason,  a  faintly  con- 
centric arrangement  is  often  given  to  such  relicts  of 
fibrillation  as  persist.  The  trabecular  become  altered, 
their  whole  tissue  becomes  infiltrated  with  lymphoid 
corpuscles,  their  fibrillation  very  indistinct,  until  at  last 


*  The  Anatomy  of  the  Lymphatic  system — the  lung.     London,  1875. 
f  For  account  of  these  vessels,  see  British  Med.  yourn. ,  loc.  cit. 


SCROFULOUS   LYMPHATIC   GLANDS.  1 33 

they  cannot  be  distinguished  from  the  adjacent  gland- 
structure,  especially  as  by  this  time  every  trace  of  the 
corresponding  sinus  will  have  been  lost.  In  this  man- 
ner spots  of  opaque  altered  tissue  appear  simultane- 
ously in  many  parts  of  the  gland ;  they  increase  in  size 
still  retaining  their  rounded  outline,  often  fuse 
together,  and  so  produce  those  conspicuous  patches 
that  have  been  so  prominently  regarded  by  all  who 
have  investigated  this  subject.  The  cell-elements  in 
these  patches  soon  indicate  a  condition  of  decay.  The 
largest  cells  are  the  first  to  perish,  and  are  soon  lost  in 
the  general  monotony  of  fatty  degeneration ;  whereas 
the  endothelial  cells  are  the  last  to  go,  and,  even  when 
caseous  changes  are  far  advanced,  will  persist,  shrivelled 
and  deformed,  as  the  sole  survivors  of  a  once  vigorous 
crowd  of  corpuscles. 

This  caseous  change  will  be  more  fully  described 
subsequently,  but  the  process  does  not  usually  end 
here  ;  on  the  other  hand,  the  caseous  districts  soften 
and  break  down,  and  suppuration  follows  in  the  man- 
ner to  be  immediately  detailed. 

Such  are  the  changes  that  occur  in  glands  that 
exhibit  the  scrofulous  process  in  its  most  intense  or 
least  chronic  form.  It  will  be  observed  that  the  pro- 
cess runs  its  course,  and  terminates  in  caseation  with- 
out either  giant-cells  or  tubercles  having  made  their 
appearance,  and  yet  it  will  be  allowed  that  the  changes 
noted  are  peculiar  and  distinctive. 

When  the  scrofulous  process  is  more  indolent  or  less 
intense,  the  appearances  as  shown  under  the  micro- 
scope are  somewhat  different  to  those  just  described ; 
and  this  difference  depends  to  a  great  extent  upon  the 
fact  that  the  more  active  or  intense  the  inflammatory 
process  the  greater  is  the  tendency  for  the  products  of 
that  inflammation  to  the  cellular  rather  than  fibrous. 
So  far  cell-elements  have  been  most  conspicuous  in  the 
process  ;  but  in  the  somewhat  less  vigorous  forms  now 
to  be  described,  it  will  be  noted  that  a  development  of 
fibrous  material  becomes  a  marked  feature. 

The  process  is  similar,  differing  only  in  degree.  The 
earlier  changes  assume  more  distinctly  the  character  of 


134  THE   PATHOLOGY   OF 

well-isolated  spots  than  they  do  in  the  form  of  the 
disease  just  cited.  The  reticulum  within  the  sinuses  is 
denser  and  more  extensive,  as  is  also  the  adenoid 
tissue  of  the  proper  gland-substance.  The  result  is, 
that  the  opaque  basis  or  ground-substance  of  the 
patches  is  now  less  homogeneous,  and  shows  more 
distinct  fibrillation  ;  the  change  being  slower,  the  cel- 
lular elements  show  more  varieties  of  outline,  and,  on 
account  of  the  prominence  assumed  by  the  fibrillar 
structure,  appear  to  be  much  less  numerous.  Now  it  is  in 
the  midst  of  such  opaque  patches  that  giant-cells  first  ap- 
pear. The  aspect  of  these  bodies  is  well-known.  It  is 
necessary  to  insist  that  they  never,  as  some  have  stated, 
commence  the  process ;  they  indicate  the  attainment  of  a 
certain  stage  in  the  inflammation,  and  never  appear,  un- 
der any  circumstances,  until  that  stage  has  been  reached. 

These  rounded  opaque  patches  with  their  giant-cells 
form  one  of  the  most  conspicuous  features  in  scrofu- 
lous gland  disease,  and  have  been  made  very  familiar 
to  all  pathologists  by  Cornil,  who  has  given  to  them 
the  title  of  "  ilots  strumeaux." 

One  word  here  as  to  the  nature  of  these  giant-cells. 
I  would  urge  that  the  so-called  giant-cells  are  merely 
lymph-coagula  involving  in  their  coagulation  a  greater 
or  less  number  of  cellular  elements.  The  reasons  for 
this  belief  are  the  following :  the  material  of  which 
the  mass  of  the  so-called  cell  is  constructed  is  precisely 
similar  to  undoubted  lymph-coagula.  These  bodies 
are  found,  under  favorable  circumstances,  distinctly  to 
occupy  the  lymphatic  sinuses  of  the  gland.  Their 
position  in  these  channels  is  not  clearly  indicated  in  the 
bulk  of  instances,  owing  to  the  rapidity  with  which  the 
anatomical  details  of  the  part  are  lost.  They  precisely 
resemble  in  every  respect  the  giant-cells  sometimes 
found  in  chronically  inflamed  connnective  tissue,  and 
that  are  located  without  doubt  in  the  lumen  of  lym- 
phatic vessels.  Their  advent  is  associated  with  the 
appearance,  throughout  the  greater  part  of  the  gland, 
of  a  material  precisely  similar  to  coagulated  lymph, 
and  that  could  hardly,  from  its  extent  and  distribution, 
be  regarded  as  protoplasm. 


SCROFULOUS   LYMPHATIC   GLANDS.  13§ 

In  opposition  to  the  theory  that  they  are  protoplas- 
mic masses,  I  would  remark  that  the  number  of  con- 
tained nuclei  bears  no  relation  whatsoever  to  the  size 
of  the  cells.  The  arrangement  of  the  nuclei  in 
some  of  these  bodies  is  so  casual  and  incoherent 
as  to  suggest  no  other  explanation  than  that  of  a 
plug  of  cells  in  a  coagulum.  Then,  again,  if  the 
cell-elements  in  the  neighboring  tissue  are  few,  the 
nuclei  of  the  giant-cell  are  few,  and  vice  versd.  Giant- 
cells  are  found  in  a  tissue  on  the  point  of  death  and 
decay,  and  in  parts  that  are  absolutely,  if  not  quite, 
non-vascular ;  and  I  cannot  conceive  that,  surrounded 
by  these  conditions,  it  is  possible  for  such  active  and 
vigorous  changes  to  ensue,  as  must  of  necessity  exist, 
if  the  protoplasmic  theory  be  correct.  It  is  urged  by 
some  that  they  are  developed  in  blood-vessels  ;  but,  as 
just  stated,  they  do  not  appear  until  the  tissue  has 
become  practically  non-vascular.  The  orderly  arrange- 
ment sometimes  noticed  in  the  nuclei  clustered  at  the 
margin  of  a  giant-cell  is  considered  conclusive  as  to  the 
origin  from  the  endothelium  of  a  blood-vessel ;  but  a 
similar  orderly  arrangement  can  be  seen  in  giant-cells 
occupying  lymphatic  vessels,  whose  endothelium  is  not 
disturbed. 

I  believe  that  these  masses  are  formed  in  the  meshes 
of  the  reticulum  that  occupies  the  sinuses,  and  also  in 
the  gland  tissue  proper.  In  the  latter  situation  they 
may  be  located  in  the  lymphatic  vessels,  to  which  I 
have  briefly  alluded.  They  indicate  the  absolute  cessa- 
tion of  all  lymphatic  current,  for,  up  to  the  time  of 
their  appearance,  the  possibility  of  a  circulation  of 
lymph  still  exists.  It  will  be  remembered  that  the  first 
changes  appear  in  the  medulla ;  its  sinuses  are  blocked, 
the  efferent  vessels  appear  quite  empty,  and  yet  the 
cortical  sinuses  are  distinct,  often  dilated.  This 
appears  to  support  the  belief  that  lymph  is  still  enter- 
ing the  gland  by  the  afferent  tracks,  and  may  be  actu- 
ally distending  the  organ,  owing  to  the  greatly 
obstructed  outflow.  I  believe  that  their  processes  are 
merely  portions  of  the  reticulum  in  which  they  are 
deposited  ;  and  it  is  a  most  significant  fact  that  the  dis- 


I36  THE   PATHOLOGY   OF 

tinctness  and  density  of  the  processes  vary  precisely 
with  the  state  of  the  surrounding  tissues.  These  pro- 
cesses are  acknowledged  to  be  continuous  with  the 
adjacent  network ;  and  so  similar  are  the  refractive 
indices  of  the  reticulum  and  the  cell-mass,  that  that 
part  of  the  reticulum  embedded  in  the  mass  is  not 
obvious.  The  shape,  moreover,  sometimes  assumed 
by  these  bodies  is  eminently  suggestive  of  a  formation 
within  a  vessel. 

In  advancing  this  view  as  to  the  nature  of  giant-cells 
I  am  alluding  only  to  the  giant-cells  of  scrofulous  or 
tuberculous  processes,  and  I  would  maintain  it  for  the 
giant-cells    incident   to   all    forms    of   these   processes. 

In  the  "Lancet"  (vol.  i.  1879)  will  ^e  found  an  excel- 
lent summary  of  the  various  views  upon  the  subject  of 
giant-cells.  From  this  account  it  will  be  seen  that 
many  pathologists  incline  to  the  opinion  that  these 
masses  are  formed  within  vessels,  and  I  would  point 
out  that  the  size  of  these  bodies  militates  against  the 
idea  that  the  are  formed  within  blood  capillaries. 
Klebs  conceives  their  origin  to  be  from  coagulated 
albuminous  bodies  in  the  lymphatics.  Koster  and 
Hering  maintain  their  origin  from  the  endothelium  of 
the  same  vessels,  and  Lubinow*  suggests  that  some  at 
least  are  formed  within  lymph  tubes.  Lanceraux,f 
speaking  of  tuberculosis  of  lymphatic  vessels,  states 
that  the  lumen  of  the  vessel  becomes  occupied  with 
cell  products  that  form  the  centre  of  the  tubercle,  and 
that  the  passage  of  lymph  is  thereby  arrested  by  a 
veritable  lymph  thrombosis. 

To  return  to  the  changes  in  the  gland.  As  the  pro- 
cess advances  caseation  begins  in  these  opaque  patches 
of  altered  tissue  or  "  ilots  strumeaux."  This  change 
is  preceded  by  certain  alterations  in  the  cell-elements 
of  the  part  that  has  been  described  by  Grancher  as 
vitreous  degeneration.:}:  It  is  not,  however,  very  well 
marked  in  the  caseous  process  in  scrofula,  but  is  best 
seen — according  to,  Grancher — in  caseous  pneumonia. 

*  Virchow's  "  Archiv.  Band.,"  lxxv.,  Heft.  i. 

J"  Traite  d'anatomie  pathologique,"  vol.  ii.  part  i.  1879,  p.  487. 
"Diet.  Encycl.,"  loc.  cit.  p.  307. 


SCROFULOUS   LYMPHATIC   GLANDS.  1 37 

The  affected  cells  become  greatly  swollen  as  if  by  some 
colloid  (vitreous)  change.  Their  protoplasm  from  being 
granular  becomes  homogeneous  and  clear,  the  nuclei 
waste  and  are  soon  lost,  and  the  cells  themselves  in 
time  fuse  together  into  a  compact  mass.  One  effect 
of  this  change  is  to  give  to  the  part  a  somewhat  gela- 
tinous aspect.  Caseation  follows.  The  caseous  pro- 
cess is  but  a  form  of  fatty  degeneration  accompanied 
by  some  desiccation  of  the  part.  It  commences  in  the 
centre  of  the  affected  tissue,  and  proceeds  towards  the 
periphery.  The  leucocytes  and  their  products  disap- 
pear early,  the  giant-cells  resist  the  change  for  some 
time,  and  the  last  cells  to  be  lost  are  the  endothelial 
cell-plates.  The  fibrous  tissue  of  the  part  survives  for 
a  while  the  simpler  elements,  and  is  then  lost  in  the 
uniformity  of  the  change.  All  that  is  to  be  seen  in  a 
caseous  spot  are  granular  debris  and  fatty  matters,  with 
here  and  there  perhaps  some  shrivelled  relics  of  what 
was  once  a  cell,  and  some  faint  fragments  of  a  fibrous 
material.  Caseation  is  generally  associated  with  some 
development  of  fibrous  tissue  in  the  adjacent  parts,  with 
a  species  of  sclerosis,  and  the  more  indolent  the  cheesy 
change,  the  more  distinct  is  this  development.  It  is 
by  the  formation  of  this  fibrous  matter  that  caseous 
masses  may  become  in  time  encapsuled,  and  rendered 
to  some  extent  inert.  Later  still  the  caseous  districts 
begin  to  soften  in  the  centre.  This  change  is  probably 
more  or  less  a  chemical  one,  and  has  been  compared  to 
the  softening  of  old  cheese.  By  the  extension  of  this 
liquefying  process  cavities  are  formed  filled  with  a 
creamy  kind  of  matter.  In  some  cases  this  may  prob- 
ably dry  up,  but  more  often  suppuration  is  excited  in 
the  adjacent  parts,  and  the  collection  becomes  puru- 
lent. Thus  arise  the  bulk  of  glandular  abscesses.  On 
the  other  hand,  it  must  be  noted  that  the  caseous 
process  may  pass  on  to  a  calcareous  change,  and  the 
whole  gland  become  converted  into  a  mortar-like 
mass. 

The  naked  eye  appearances  presented  by  glands  of 
this  class  vary  considerably.  In  the  earliest  stages  the 
gland  when  cut  open  shows  a  pale  flesh-colored  section, 


I38  THE   PATHOLOGY   OF 

and  is  soft  and  uniform  in  density.  As  the  disease 
advances  the  color  becomes  somewhat  paler,  and  the 
texture  of  the  mass  of  greater  firmness.  The  tissue, 
moreover,  has  a  clear,  semi-transparent  aspect,  so  that 
when  a  small  gland  mass  is  held  up  to  the  light  it 
appears  fairly  translucent,  especially  about  its  periphery. 
Moreover,  when  caseous  nodules  exist  they  can  often 
be  detected  at  some  little  depth  from  the  surface  of  the 
section,  and  if  the  gland  tumor  that  contains  a  cheesy 
nodule  be  small — no  larger,  for  example,  than  a  horse 
bean — the  little  mass  can  often  be  recognized  by  its 
opacity  when  the  uninjured  gland  is  held  up  to  the 
light.  Before  cheesy  nodules  are,  however,  apparent, 
some  parts  of  the  gland  become  of  a  paler  color ;  and 
loosing  their  translucency  look  dull  and  more  opaque 
than  the  tissues  around.  This  alteration  may  be  limited 
to  very  minute  specks  scattered  over  the  surface  of  the 
section,  but  more  often  it  is  restricted  to  one  or  two 
patches  of  fair  size.  These  larger  patches  are  gener- 
ally indistinct  in  their  outlines.  The  color  of  these 
parts  becomes  paler  and  paler,  their  aspect  more  and 
more  opaque,  until  they  assume  the  appearance  of 
caseous  change.  The  caseous  districts  vary  greatly  in 
the  features  they  present.  Usually,  they  are  extremely 
well  limited,  and  project  sharply  above  the  cut  surface 
of  the  gland  when  it  has  been  sliced  open.  They  vary 
in  color  from  a  dull  white  to  a  faint  grey  or  a  fainter 
yellow,  and  often  the  central  part  of  the  spot  is  of  a 
different  color  to  the  periphery.  The  size  of  the 
caseous  spots  varies.  They  may  be  as  small  as  hemp- 
seeds  or  large  enough  to  occupy  almost  the  entire  gland. 
They  may  be  single  or  multiple,  and  exhibit  the  greatest 
irregularity  in  outline.  There  is  no  connection  between 
the  size  of  the  gland  and  the  extent  of  the  caseous 
change.  A  little  gland  no  larger  than  a  horse  bean 
may  be  wholly  caseous,  while  a  tumor  one  inch  in 
length  may  show  on  section  but  a  few  minute  specks  of 
that  degeneration.  In  more  advanced  periods  of  the 
disease  purulent  cavities  appear  in  the  gland,  which 
when  fully  formed  are  filled  with  a  creamy  kind  of  pus 
of  a  peculiarly  greenish  color,  very  like  that  of  a  duck's 


SCROFULOUS   LYMPHATIC   GLANDS.  1 39 

egg.  Some  of  the  more  chronic  of  these  glands  may 
attain  great  size  before  they  caseate,  and  I  have  no 
doubt  that  it  is  to  these  homogeneous  tumors  that  the 
term  hypertrophy  has  been  applied,  especially  as  they 
retain  for  a  long  while  more  or  less  the  aspect  of  the 
normal  gland. 

2.  The  glands  placed  in  this  division  are  those  that 
show  the  more  indolent  phases  of  the  scrofulous  pro- 
cess. The  whole  morbid  action  in  these  bodies  is 
leisurely,  and  serves  to  exhibit  the  most  perfect  attain- 
ment of  the  strumous  change,  of  which  indeed  they 
exhibit  the  least  intense  aspect.  Chronicity  is  hardly 
the  term  to  use  in  comparing  various  changes  in  scrofu- 
lous disease.  The  question  of  time  is  one  too  uncer- 
tain to  be  of  use  as  a  means  of  comparison,  as  the  gland 
disease  is  in  all  cases  apt  to  progress  with  the  utmost 
irregularity. 

In  the  glands  placed  in  this  division  a  production  of 
fibrous  tissue  is  the  most  conspicuous  element.  In  the 
other  forms  of  strumous  gland  just  described  there  is  a 
tendency  for  the  morbid  tissnes  to  assume  more  or  less 
rounded  ontlines,  and  to  arrange  themselves  in  the  form 
of  spots  or  patches.  So  in  the  present  instance  it  will 
be  found  that  the  fibrous  matter  so  conspicuous  in 
these  bodies  is  prone  to  display  itself  in  more  or  less 
rounded  masses,. and  to  produce  in  consequence  some 
very  definite  appearances. 

In  some  cases,  these  rounded  masses  are  so  dense  as 
to  appear  quite  solid,  the  contained  cell-elements  being 
scanty  and  withered  ;  they  can  be  isolated  by  shaking, 
and,  although  they  present  no  characters  that  would 
now  distinguish  them  as  tubercle,  yet  in  less  recent 
descriptions  they  have  received  that  name.  In  other 
districts  will  be  seen  a  rounded  spot,  occupied  by 
a  more  or  less  open  but  irregular  fibrous  structure, 
that  often  presents  a  concentric  arrangement  at  its 
edge.  Such  an  area  contains  different  degenerate  cell- 
elements,  the  periphery  and  adjacent  tissue  being  at 
the  same  time  probably  occupied  by  lymph-corpuscles, 
but  little  altered.  Throughout  all  parts  of  the  affected 
spot  can  be  seen  the  homogeneous  material  that  closely 


140  THE   PATHOLOGY   OF 

resembles  coagulated  lymph.  In  other  instances, 
giant-cells  are  introduced  into  these  spaces,  and  the 
appearance  denominated  tubercle  is  produced.  Into 
the  reputed  structure  of  the  true  reticular,  lymphoid,  or 
submiliary  tubercle,  I  have  already  entered.  It  is 
sufficient  to  refer  to  the  fibrous  material  so  arranged  as 
to  include  a  more  or  less  circular  space,  with  a  giant- 
cell  in  or  about  its  centre  possessing  branched  processes 
that  reach  the  periphery :  and  casually  to  mention  the 
larger  and  smaller  cell-masses  that  occupy  the  tissue 
between  the  giant-cell  and  the  periphery,  and  that  are 
considered  to  represent  all  gradations  between  that 
cell  and  the  little  lymph-corpuscles  that  may  crowd  the 
outskirts  of  the  tubercle. 

Many  of  the  affected  districts,  however,  contain  no 
giant-cells  ;  others  only  show  the  circular  arrangement  of 
the  fibres,  or  show  giant-cells  with  no  definite  fibrous 
arrangement ;  while  another  part  contains  few,  if  any, 
of  the  corpuscles  that  are  considered  typical  of  the 
appearance.  Certain  is  is  that,  with  the  appearance  of 
this  tubercle,  the  process  ends,  and  degeneration  of  a 
gross  character  immediately  ensues. 

I  would  urge  for  the  giant-cells  found  in  tubercle  a 
like  nature  to  that  I  have  ascribed  to  those  bodies  in 
dealing  with  the  previous  class  of  gland  tumor.  The 
circular  outline  often  noted  in  these  tubercles  appears 
to  be  merely  a  circumstance  in  the  inflammatory  process, 
by  no  means  peculiar  or  specific.  The  anatomical 
details  of  the  sinuses  are  no  longer  obvious  in  gland- 
tissue  presenting  tnbercle ;  but  I  would  still  urge  that 
these  giant-cells  are  lymph-coagula  formed  in  the  irreg- 
ular meshes  of  the  now  quite  disordered  stricture. 
Some  districts  show  no  giant-cells,  but  in  their  place 
the  material  that  is  in  no  way  different  from  a  coagulum. 
The  masses,  moreover,  are  as  often  seen  at  the  peri- 
phery as  in  the  centre  of  the  supposed  tubercles,  and 
the  smaller  giant-cells  would  represent  smaller  coagula. 
The  connection  of  the  processes  of  one  giant-cell  with 
those  of  another,  and  the  still  further  connection  of 
those  processes  with  the  surrounding  reticulum,  is 
fully  explained  on  the  supposition  that  these  giant-cells 


SCROFULOUS   LYMPHATIC   GLANDS.  141 

are  coagula  deposited  haphazard  in  the  meshes  of  the 
fibrous  tissue  of  the  gland,  and  that  they  conceal  the 
reticulum  to  an  extent  equivalent  to  the  size  of  the 
coagulum  or  so-called  cell. 

In  proof  of  this  I  would  call  attention  to  the  figure 
of  a  giant-cell  taken  from  the  edge  of  a  caseous  patch 
This  giant-cell  and  the  surrounding  tissues  are  de- 
generating; and  when  such  degeneration  takes  place, 
the  cellular  elements  and  the  lymph-coagulum  are 
always  the  first  to  perish,  the  fibrous  elements  resist- 
ing for  a  longer  period  the  caseous  action,  and 
acquiring  thereby  a  temporary  distinctness.  Therefore, 
if  the  giant-cell  is  deposited  in  a  reticulum  and  bolts 
out  by  its  very  substance  the  details  of  that  reticulum, 
it  is  obvious  that,  as  the  mass  degenerates,  the  fibres  of 
that  mesh-work  should  again  become  apparent.  Now, 
in  this  decaying  giant-cell,  a  fibrous  mesh-work  can  be 
seen  stretching  across  the  mass,  exactly  similar  to  that 
observed  in  the  vicinity;  and  especially  it  is  to  be 
noticed  that  this  reticulnm  is  continuous  with  the 
so-called  processes  of  the  giant-mass,  and,  through  them 
with  the  adenoid  tissue  in  the  neighborhood.  The 
appearance  of  fibrous  matter  in  moribund  giant-cells 
has  been  observed.  Klein,  in  speaking  of  the  giant- 
cells  in  tubercle  of  the  lung,  states  that,  before  under- 
going final  decay  they  are  often  converted  into  a 
fibrillar  substance  ;  on  this  point,  however,  I  would 
urge  that  the  development  of  fibrous  material  in  a 
tissue  partly  decayed  and  quite  destitute  of  blood- 
supply  would  seem  scarcely  probable. .  Slowly  a  caseous 
degeneration  spreads  over  these  glands,  and  in  more 
advanced  instances  that  ends  in  suppuration. 

The  naked  eye  appearances  presented  by  these  bodies 
on  section  are  at  first  somewhat  akin  to  those  described 
in  the  former  examples  of  the  disease,  although  they 
never  appear  so  vascular  nor  so  brightly  colored.  In 
time  the  section  becomes  dull  and  opaque,  and  an  insid- 
ious cheesy  metamorphosis  creeps  over  the  diseased 
tissue.  The  suppuration  when  it  occurs  is  more  dif- 
fused, and  throughout  there  is  always  evidence  of 
abundant  fibrous  material  in  the  parts. 


142  THE  PATHOLOGY  OF 

This  fibrous  matter  may  be  so  extensive  as  to  render 
the  gland  tough  and  firm  in  some  portions  of  it,  and  to 
cause  it  even  to  creak  under  the  knife  when  cut. 

In  all  cases  of  gland  disease  in  struma,  there  is  more 
or  less  thickening  of  the  capsule,  but  in  the  present 
instance  that  thickening  reaches  its  greatest  develop- 
ment. As  will  be  seen  in  the  chapter  that  deals  with 
local  treatment,  this  increased  density  of  of  the  capsule 
is  of  good  service  when  an  attempt  is  made  to  remove 
the  diseased  contents  of  the  body  by  scooping. 

Those  who,  like  Cornil,  maintain  a  distinction  between 
the  scrofulous  and  tubercular  processes,  as  they  term 
them,  would  designate  the  gland  affections  dealt  with 
in  Class  I.  "  scrofulous,"  and  those  dealt  with  in  Class 
II.  "  tuberculous."  This  distinction  is  to  a  great  extent 
a  mere  matter  of  terms,  inasmuch  as  there  is  great  una- 
nimity in  the  accounts  given  of  the  morbid  appearances 
by  those  who  hold  the  most  opposite  views  as  to  their 
nature.  An  examination  of  many  glands  in  various 
stages  from  the  same  case  will  show  that  there  is  no 
line  of  demarcation  between  the  changes  incident  to 
glands  of  the  first  class  and  those  of  the  second.  The 
glands  that  show  tubercle  present  in  their  earlier  stages 
appearances  identical  with  those  seen  in  glands  that 
show  Cornil's  "  ilots  strumeaux,"  although  in  the  former 
instance  those  appearances  are  much  modified  by  the 
greater  indolence  of  the  process. 

It  has  been  asserted  that  in  the  so-called  "  scrofulous 
gland  "  the  change  commences  in  the  connective  tissues 
of  the  part,  and  is  a  true  interstitial  adenitis,  whereas 
in  the  "  tubercular  gland  "  it  commences  in  the  lymph- 
atic vessels  and  sinuses,  and  is  a  species  of  catarrh. 

Such  distinctions,!  must  say,  are  not  obvious.  Take 
a.case  of  gland  disease  that  would  accord  with  Cornil's 
description  of  the  "  scrofulous  gland,"  and  among  the 
masses  removed  will  very  possibly  be  found  a  few 
minute  glandular  bodies  that  are  just  beginning  to  be 
invaded  by  disease.  I  have  examined  many  such,  but 
never  have  I  observed  at  the  commencement  of  the 
process  any  changes  in  the  connective  tissue  elements. 

The  clinical  distinctions  between  these  two  classes  of 


SCROFULOUS  LYMPHATIC  GLANDS.  143 

gland  tumor  are  generally  well  marked.  The  glands  of 
the  first  class  enlarge  tolerably  quickly,  although  the 
matter  of  time  must  not  be  too  strictly  weighed,  as  at 
any  stage  the  process  may  remain  quiescent  for  a  long 
period.  Their  progress  may  be  marked  by  inflamma- 
tory symptoms.  They  are  apt  to  attain  large  size, 
forming,  indeed,  the  largest  individual  gland  tumors  of 
scrofula.  They  tend  to  become  matted  together.  They 
caseate  early,  and  show  a  very  fairly  constant  disposi- 
tion to  suppurate. 

Those  of  the  second  class  increase  in  a  very  indolent 
and  insidious  manner  ;  their  progress  is  marked  by  an 
utter  absence  of  any  inflammatory  symptoms.  They 
may  form  by  extension  large  gland  collections,  but  the 
individual  glands  are  seldom  of  great  size.  There  is 
no  periadenitis,  but  the  tumors  remain  freely  moveable. 
Caseation  appears  slowly,  and  these  glands  show  but  a 
very  slight  disposition  to  suppurate,  and  that  only  in 
advanced  cases.  The  cases  not  infrequently  met  with 
of  persistent  and  well-marked  enlargement  of  one  gland 
(or  at  the  most  of  one  or  two  glands)  belong,  I  think, 
in  every  instance  to  the  first  division  of  gland  enlarge- 
ments. 

One  matter  concerned  in  the  pathology  of  this  affec- 
tion remains  to  be  considered.  The  manner  in  which 
strumous  gland  disease  spreads.  Some  cases  of  spread- 
ing gland  disease  may  be  explained  by  assuming  that 
the  peripheral  irritation  that  caused  the  first  gland  to 
enlarge  is  still  active,  and  is  spreading  along  the  other 
lymphatics  to  other  glands.  Other  cases  may  be. 
explained  on  the  grounds  that  many  glands  may  be 
simultaneously  affected  from  one  source  of  irritation. 
But  these  explanations  will  not  cover  all  instances  of 
extensive  or  extending  gland  disease  in  scrofula. 

One  constantly  meets  with  cases  where  glands  are 
involved,  one  after  the  other,  in  a  very  regular  succes- 
sion, and  in  a  direction  often  actually  the  reverse  to 
that  of  the  lymph-current.  From  some  definite  peri- 
pheral irritation  a  gland  may  enlarge  just  above  the 
clavicle,  and  be  followed,  in  the  absence  of  any  fresh 
irritation,  by  a  series  of  glands  that  will  appear  in  order 


144  THE   PATHOLOGY   OF 

one  after  the  other,  and  mount  up  the  neck,  the  last 
gland  affected  being  that  nearest  the  jaw.  In  such  a 
case,  it  may  be  urged  that  the  circulation  of  lymph  is 
so  interfered  with  by  the  implication  of  the  orignal 
gland,  that  a  species  of  backward  stasis  is  produced, 
and  the  diseased  lymph  thrown  thereby  into  collateral 
channels.  In  the  same  way  it  is  very,  common  to  see 
gland-mischief  extend  from  the  neck  into  the  axilla, 
in  a  most  precise  order,  and  by  direct  continuity  of 
parts. 

The  microscope,  however,  reveals  another  explana- 
tion ;  the  diseased  process  may  actually  be  followed 
from  the  gland-tissue  back  into  the  capsular  plexus, 
and  thence  into  the  afferent  vessels  :  these  latter  become 
blocked  up  by  the  corpuscular  elements,  develop  within 
their  lumen  a  reticulum,  just  as  observed  by  Klein  *  in 
inflamed  lymphatics  elsewhere,  undergo  all  the  scrofu- 
lous changes,  and  become  in  time  caseous.  I  imagine 
that,  by  means  of  these  vessels,  connected  glands  may 
be  affected,  especially  as  one  finds  connecting  lines  of 
diseased  tissue  running  from  one  gland  to  another. 
Moreover,  this  morbid  change  can  extend  along  the 
vessels,  independently  of  valves,  and  in  the  reverse 
direction  to  the  lymph  current. 

Then,  again,  it  is  well  known  that  the  larger  glandular 
masses  may  present  more  separate  gland-bodies  than 
can  be  accounted  for  by  the  anatomist.  Many  of  these 
are  no  doubt  due  to  the  enlargement  of  glands  so  small 
in  health  as  to  escape  the  eye  of  the  dissector.  And, 
again,  I  have  repeatedly  found  little  glands  wholly 
caseous,  which  are  yet  no  larger  than  hemp-seeds. 
Now,  I  believe  that  many  of  these  apparently  super- 
numerary bodies  are  produced  from  the  afferent  lym- 
phatics of  the  adjacent  diseased  glands  by  the  follow- 
ing process.  Klein  has  shown  that  irritated  lymphatic 
vessels  very  readily  develop  into  masses  of  adenoid 
tissue  surrounded  by  a  perfect  sinus,  which  sinus  is 
nothing  indeed  but  the  altered  vessel  itself.  These 
little   masses   may   assume    the    features  of    a  gland 

*  "  Anatomy  of  the  Lymphatic  System,"  loc.  cit. 


SCROFULOUS   LYMPHATIC   GLANDS.  I45 

(although  they  retain  a  much  more  rudimentary  struc- 
ture), are  quite  capable  of  increasing  indefinitely,  of 
showing  the  whole  of  the  changes  incident  to  scrofula ; 
and  I  have  no  doubt  that  they  form,  in  time,  many  of 
the  bodies  that  are  not  to  be  distinguished  from  the 
ordinary  lymph-glands. 

This  tendency  to  local  infection  or  to  spreading  of 
disease  by  direct  continuity  of  tissue  is  of  considerable 
importance  in  discussing  the  operative  measures  pro- 
posed for  the  treatment  of  these  gland  affections. 


CHAPTER  XIII. 

SYMPTOMS  AND  DIAGNOSIS  OF  SCROFULOUS  LYMPHATIC 
GLANDS. 

Scrofulous  gland  tumors  exhibit  the  greatest  variety, 
not  only  in  their  physical  character,  but  also  in  their 
progress  and  tendencies. 

In  one  individual  the  most  diverse  conditions  of 
gland  tumor  may  be  observed.  The  same  patient  may 
exhibit  masses  more  or  less  advanced  in  destruction  by 
the  side  of  minute  glands  that  show  but  the  earliest 
evidences  of  disease,  and  may  be  the  subject  at  one  and 
the  same  time  of  gland  enlargements  that  have  pro- 
gressed with  rapidity,  and  of  other  enlargements  that 
have  been  practically  quiescent  for  years. 

The  commencement  of  the  gland  mischief  in  scrofula 
is  usually  very  insidious.  Most  commonly  the  enlarged 
bodies  are  discovered  by  accident  on  the  patient  casually 
passing  his  hand  over  the  neck  or  other  affected  part. 
Sometimes  the  gland  tumor  reaches  considerable  size 
before  it  is  discovered,  and  this  is  especially  the  case 
with  disease  of  the  axillary  glands.  This  casual  dis- 
covery of  masses  that  have  already  attained  large  size 
is  probably  the  foundation  of  many  of  the  accounts  of 
reputed   sudden  glandular  enlargement.     In  nearly  all 


I46  SYMPTOMS  AND   DIAGNOSIS   OF 

cases  there  is  at  first  an  utter  absence  of  any  pain  or 
tenderness  in  the  part,  and  of  any  of  the  ordinary  signs 
of  inflammation,  the  process  being  essentially  indolent 
and  chronic.  In  some  rare  instances  the  gland  disease 
may  commence  with  symptoms  of  active  inflammation, 
a  circumstance  observed  usually  in  quite  young  child- 
ren and  in  cases  of  the  disease  that  have  followed  upon 
the  eruptive  fevers.  In  the  latter  instance  the  activity 
of  the  inflammation  depends  probably  rather  on  the 
exanthem  than  upon  any  scrofulous  influence.  As  a 
general  rule  it  may  be  said  that  the  more  marked  the 
evidences  of  struma  in  any  patient  the  more  disposed 
will  the  gland  affection  be  towards  a  chronic  course ; 
and  I  think  it  is  true  that  the  examples  of  more  active 
gland  disease  are  for  the  most  part  met  with  iu  those 
who  exhibit  but  slight  proofs  of  the  scrofulous  disposi- 
tion. It  may,  however,  be  here  observed  that  in  exten- 
sive and  spreading  gland  disease  the  invasion  of  a  new 
cluster  of  glands  is  occasionally  marked  by  some  pain 
and  tenderness  and  some  undue  heat  in  the  part. 

Before  dealing  with  the  grosser  forms  of  gland  dis- 
ease, it  is  well  to  note  that  in  making  a  careful  examina- 
tion of  the  neck  in  some  strumous  children  who  appear 
free  from  lymphatic  affection,  one  may  often  detect 
(especially  along  the  posterior  triangle)  a  number  of 
small,  distinct,  hard,  and  freely  moveable  glands  that 
should  not  be  obvious  in  health.  These  slightly 
enlarged  glands  may  persist  for  some  of  the 
earlier  years  of  the  child's  life,  and  while  they  are  apt 
to  temporarily  enlarge,  during  any  disturbance  of  the 
patient's  health,  they  soon  return  to  their  normal,  size 
again  ;  and,  giving  no  further  trouble,  disappear  at 
puberty. 

Strumous  disease  may  appear  simultaneously  in  many 
glands,  or  may  commence  in  one  and  remain  for  a  long 
time  limited  to  it.  I  have  notes  of  cases  where  only 
one  gland  has  been  affected,  which  gland  has  attained 
fair  size,  and  undergone  the  whole  scrofulous  change 
without  the  appearance  of  any  fresh  disease  in  the 
vicinity.  The  affected  glands  in  any  case  are  recog- 
nized at  first  as  small,  distinct,  and  very  freely  move- 


SCROFULOUS   LYMPHATIC   GLANDS.  1 47 

able  bodies,  that  readily  slip  under  the  finger.  They 
are  round  or  oval,  but  most  commonly  bean-shaped, 
and  feel  very  firm  and  resisting,  and  often  remarkably 
hard.  Certain  of  these  glands  increase  in  size,  and 
attain  the  dimensions  of  a  filbert,  or  even  of  a  bantam's 
egg,  and  yet  remain  perfectly  mobile ;  and,  although 
softer  than  when  first  noticed,  are  nevertheless  elastic, 
firm,  and  throughout  of  equal  density. 

The  number  of  such  glands  may  increase  consider- 
ably, and  extensive  chains  of  diseased  masses  be  formed, 
the  common  characters  of  the  tumors  being  still 
retained.  Thus  in  the  neck  large,  irregularly  lobulated 
tumors  may  be  formed  that  are  moveable,  painless, 
covered  with  healthy  skin,  and  that  can  be  felt  to  be 
made  up  of  a  number  of  distinct  and  but  feebly  adher- 
ent lymphatic  bodies.  The  morbid  changes  in  such 
tumors  will  be  probably  such  as  are  described  in  the 
chapter  on  their  pathology  under  Class  II.  The  course 
of  this  variety  of  the  glandular  tumor  is  usually  very 
indolent,  and  the  enlargement  commonly  proceeds  in 
an  irregular  manner. 

Other  glands  increase  somewhat  more  rapidly,  and 
not  infrequently  with  some  local  evidences  of  inflam- 
mation. They  may  form  very  large  tumors,  and  pro- 
duce considerable  deformity.  Neighboring  glands 
become  matted  together,  and  so  great  lobulated  masses 
are  produced,  that  become  adherent  to  the  deeper 
parts,  and  subsequently  to  the  skin.  These  glands 
soon  present  to  the  touch  different  degrees  of  density, 
and  become  softened  in  places.  In  time,  in  most 
instances,  suppuration  will  ensue,  of  which  more  will  be 
said  subsequently.  These  are  the  glands  that  become 
caseous  comparatively  early,  and  it  is  important  to 
note  the  fact  of  their  becoming  adherent  is  evidence  of 
their  containing  some  purulent  or  quasi-  purulent  col- 
lections. The  adhesions  formed  by  these  tumors  are 
due,  as  already  stated,  to  an  inflammation  set  up  in 
the  soft  parts  about  the  gland.  If  only  single  glands 
are  enlarged  they  usually  follow  the  course  just 
detailed,  and  as  regards  actual  numbers,  fewer 
glands    are    involved    in    these    masses    than    is    the 


I48  SYMPTOMS  AND   DIAGNOSIS   OF 

case  with  the  species  of  gland  disease  previously 
mentioned. 

Speaking  generally,  the  gland  affections  in  scrofula 
are  not  symmetrical,  and  if  symmetry  be  observed  in  a 
few  instances  it  is  probably  but  a  coincidence.  An 
exception,  however,  is  afforded  to  this  rule  in  certain 
cases  of  gland  enlargement  depending  upon  hypertro- 
phy of  the  tonsil.  Here  symmetrically  placed  glands 
are  often  to  be  felt  in  the  neck  at  the  level  of  the  hyoid 
bone.  Glands  that  simultaneously  commenced  to 
be  enlarged  do  not  usually  all  progress  at  the  same 
rate  and  in  the  same  manner.  In  a  chain  of  diseased 
glands  that  were  at  one  time  all  of  the  same  size  and 
condition,  some  will  in  awhile  be  found  much  enlarged 
and  advanced  in  disease,  while  others  are  still  but  little 
altered.  And  in  most  instances  it  is  impossible  to 
detect  any  cause  for  this  irregular  progress.  As  may 
be  supposed,  the  glands  that  are  the  nearest  to  any 
source  of  peripheral  irritation  are  the  ones  most 
severely  affected,  but  even  this  relation  would  not 
appear  to  hold  good  in  every  case. 

The  progress  of  strumous  gland  disease  is,  as  already 
noted,  most  variable  and  uncertain.  Glands  may 
enlarge  rapidly  and  then  become  quiescent,  and  remain 
stationary  for  indefinite  periods,  that  may  sometimes 
be  estimated  by  years.  Or,  on  the  other  hand,  enlarge- 
ments that  have  pursued  an  indolent  course  from  the 
commencement  may  abruptly  take  on  more  active 
change,  and  speedily  end  in  suppuration.  Glands  that 
have  attained  certain  dimensions  may  subside  more  or 
less,  and  then  enlarge  again ;  and  this  phenomenon 
may  be  exhibited  more  than  once  in  the  same  set  of 
gland  tumors.  There  is  no  doubt  that  this  local  affec- 
tion is  considerably  influenced  by  the  general  health  of 
the  patient.  At  puberty  a  marked  improvement  is 
often  observed  in  gland  affections  that  have  given  much 
trouble  in  childhood,  and  this  improvement  not  uncom- 
monly amounts  to  perfect  cure.  In  adults  the  state  of 
the  local  mischief  is  greatly  influenced  by  the  patient's 
condition,  and  this  is  especially  observed  in  connection 
with  pregnancy  and  parturition.     These  conditions  are 


SCROFULOUS   LYMPHATIC   GLANDS.  149 

often  attended  by  the  outbreak  of  a  gland  disorder  that 
had  perhaps  been  long  quiescent. 

In  some  cases  an  absolute  reappearance  of  gland  mis- 
chief will  occur  in  connection  with  defects  in  general 
health.  Such  cases  may  be  illustrated  by  this  exam- 
ple. The  patient,  when  a  child,  had  scrofulous  glands 
in  the  neck  that  suppurated  and  left  conspicuous  scars, 
but  no  trace  of  any  remaining  glandular  enlargement. 
He  was  free  from  any  trace  of  struma  until  the  age  of 
twenty-two,  when  large  gland  tumors  again  appeared 
in  the  neck,  and  led  to  extensive  suppuration  in 
less  than  twelve  months.  Previous  to  the  onset  of 
this  fresh  disease,  the  patient  had  been  very  dis- 
sipated, and  had  in  consequence  suffered  greatly  in 
health. 

Resolution  may  occur  at  various  stages  and  in  many 
different  kinds  of  gland.  Those  cases  where  children 
exhibit  a  slight  but  uniform  and  very  chronic  enlarge- 
ment of  many  glands  (the  largest,  perhaps,  not  larger 
than  a  hazel  nut)  usually  do  well,  and  at  puberty  all 
trace  of  the  disease  may  disappear.  Single  glands 
more  commonly  undergo  resolution  than  do  the  collec- 
tions made  up  of  several  glandular  tumors.  It  is  diffi- 
cult to  say  how  far  strumous  disease  may  advance  and 
still  cure  without  suppuration  be  possible.  It  is  cer- 
tain that  gland  tumors  of  large  size  that  have  become 
matted  together,  and  that  are  known  to  contain  at  least 
quasi-purulent  collections,  may  subside  and  shrink,  and 
cease  forever  to  give  the  patient  trouble,  although 
there  may  be  always  some  evidence  of  their  presence. 
Certain  of  such  glands  become  calcareous  and  thereby 
inert ;  but  that  final  change  is  less  frequent  among  the 
lymphatic  bodies  of  the  surface  than  it  is  among  those 
within  the  cavities  of  the  body.  I  think  that  the  medi- 
astinal and  bronchial  glands  furnish  the  largest  number 
of  instances  of  calcareous  change. 

Resolution  is  least  common  in  those  insidious  gland- 
ular tumors  that  increase  within  certain  limits,  and  yet 
spread  along  a  whole  chain  of  lymphatics,  and  that,  on 
microscopic  examination,  are  found  to  contain  well- 
developed  tubercle.  Resolution,  or  cure  without  suppur- 


150  SYMPTOMS   AND   DIAGNOSIS   OF 

ation,  is  much  more  common  in  children  than  in  adults  ; 
and,  indeed,  in  the  latter  it  is  very  rare. 

Cases  are  recorded  of  gland  enlargements  having  dis- 
appeared under  the  influence  of  measles,  scarlet  fever, 
and  angina,*  and  a  like  happy  result  is  stated  to  have 
occurred  after  an  attack  of  erysipelas  of  the  face.f 

Suppuration. — The  majority  of  scrofulous  gland 
tumors  at  some  time  or  another  end  in  suppuration. 
What  percentage  thus  terminate  it  is  impossible  to  say. 
Reliable  statistics  upon  this  point  can  scarcely  be 
attainable,  inasmuch  as  cases  are  not  long  enough  under 
observation  ;  and,  moreover,  few  surgeons  can  enjoy  a 
practice  that  would  include  a  sufficiently  large  number, 
both  of  the  most  trifling  and  of  the  most  serious  exam- 
ples of  the  disease. 

Those  who  have  written  upon  the  subject  have  come 
to  the  most  diverse  conclusions.  Price:}:  states  that 
suppuration  occurred  in  82  cases  out  of  140  examples 
of  cervical  gland  disease  that  came  under  his  notice, 
and  observes  that  it  would  probably  occur  in  time  in 
the  remaining  cases.  On  the  other  hand,  Phillips§ 
remarks  that  "  of  twenty  persons  suffering  from  sensibly 
enlarged  glands,  in  scarcely  more  than  one  will  they 
proceed  to  suppuration."  In  the  131  examples  of  cer- 
vical gland  disease  obtained  from  the  Margate  records, 
suppuration  had  occurred  in  93  instances. 

The  following  are  the  principal  facts  about  suppura- 
tion in  scrofulous  lymphatic  affections.  Suppuration  is 
infinitely  more  common  in  the  external  glands  than  in 
those  in  the  interior  of  the  body.  It  is  also  more  com- 
mon in  the  superficial  series  of  external  glands  than  in 
the  deep.  The  greater  number  of  instances  of  inert 
caseous  glands  and  of  calcareous  change  will,  so  far  as 
the  neck  is  concerned,  be  found  in  the  most  deeply 
seated  of  the  cervical  lymphatic  bodies.  From  what 
has  been  already  said  it  will  be  gathered  that  suppura- 

*  Des  adenopathies  chez  les  scrofuleux.     "  These  de  Paris,  1877,"  by 
Dr.  Legendre. 

f  Two  cases  are  given  by  Deligny,  "loc.  cit.,"  p.  66. 
±  Loc.  cit.,  p.  72. 
§  Loc.  cit.,  p.  11. 


SCROFULOUS   LYMPHATIC    GLANDS.  I$I 

tion  occurs  with  much  greater  frequency  in  adults  than 
in  children.  Suppuration  is,  however,  often  early  and 
severe  in  gland  disease  in  infants.  With  regard  to  the 
period  in  the  disease  at  which  suppuration  occurs,  it  is 
impossible  to  speak  precisely.  I  think  the  average 
period  may  be  estimated  by  years  rather  than  by 
months.  Some  slight  light  is  thrown  upon  this  matter 
by  noting  the  duration  of  non-suppurating  gland  affec- 
tious.  The  Margate  cases  show  that  the  average 
duration  *  of  such  affections  is  3.5  years  ;  the 
maximum  period  being  12  years  and  the  minimum 
a  matter  of  months.  It  is  certain  that  suppuration 
occurs  as  a  rule  at  an  earlier  period  of  the  disease  in 
adults  than  it  does  in  children.  I  observe,  also,  that 
healing  occurs  more  quickly  when  the  glands  have  sup- 
purated early  than  when  they  suppurate  late,  a  fact 
that  may  be  well  surmised.  Observations  I  have  made 
in  a  large  number  of  cases  establish  the  interesting  fact 
that  the  presence  of  other  strumous  manifestations 
evry  markedly  delays  suppuration  in  the  glands. 

Local  Evidences  of  suppuration. — There  are  two  dis- 
tinct forms  of  "  glaudular  abscess"  in  scrofulous 
cases.  In  one  instance  the  suppuration  is  in  the  gland 
itself,  and  is  limited  by  its  capsule  up  to  a  certain  point ; 
in  the  other  example,  the  suppuration  is  in  the  con- 
nective tissue  outside  the  gland  (peri-adenitis),  and  has 
of  necessity  no  communication  with  any  purulent  col- 
lection within  the  tumor.  It  is  important  when  possible 
to  distinguish  between  these  two  abscesses.  To  take  a 
typical  example  of  each  form. 

1.  The  gland  abscess  proper. — A  gland  mass  that  has 
existed  for  some  time  and  has  attained  good  size  has 
become  adherent  to  the  deeper  parts  and  to  the  skin. 
From  being  hard  it  becomes  of  unequal  density,  and 
feels  less  resisting  in  places.  The  outline  of  this  gland 
is  distinct,  although  before  the  pus  escapes  it  may  be 
obscured  by  an  oedema  set  up  in  the  adjacent  parts. 
The  mass  becomes  tender  and  painful,  and  the  part  hot. 

*  By  this  term  I  mean  the  length  of  time  the  disease  had  existed  when 
the  patient  came  under  notice. 


152  SYMPTOMS   AND   DIAGNOSIS   OF 

The  skin  over  the  most  prominent  portion  of  the 
tumor  is  red  and  cedematous.  It  then  becomes  more 
and  more  thinned  and  of  a  purplish  tint,  and  at  last 
gives  way  and  allows  the  pus  to  escape.  Before  the 
skin  has  yielded  a  sense  of  fluctuation  may  be  evident. 
It  is,  however,  of  limited  extent,  and  gives  rather  the 
impression  of  a  soft  and  elastic  spot  in  the  midst  of  the 
denser  substance  of  the  gland  mass.  The  pus  is 
usually  thin,  and  contains  curdy  grumous  fragments 
that  crush  under  the  finger,  and  that  represent  undis- 
solved portions  of  the  caseous  mass.  If  the  opening 
can  be  examined,  at  the  bottom  will  be  seen  the  ragged 
interior  of  a  disorganized  gland  tumor,  and  perhaps 
much  unaltered  cheesy  matter.  The  discharge  con- 
tinues so  long  as  any  diseased  tissue  has  to  come  away  ; 
then  granulations  arise,  and  in  favorable  cases  the 
abscess  cavity  is  filled  up  and  the  sinus  closed, 

2.  The  abscess  outside  the  gland. — This  generally 
occurs  in  connection  with  processes  of  some  activity, 
and  the  abscess  may  form  around  a  gland  of  still  small 
size  and  not  yet  adherent  to  the  skin.  , 

Owing  to  the  inflammatory  changes  in  the  soft  parts 
around  it,  the  outline  of  the  gland  is  soon  entirely  lost, 
and  the  ordinary  evidence  of  an  abscess  in  the  sub- 
cutaneous tissues  become  apparent.  These  evidences 
are  often  obscured  by  the  presence  of  other  gland 
tumors  in  the  vicinity.  The  part  becomes  tender,  and 
hot.  The  skin  becomes  red  over  a  larger  area  than  is 
affected  in  the  former  instance,  and  when  it  gives  way 
often  does  so  by  a  larger  opening.  Fluctuation  is  much 
more  evident  than  in  the  case  of  the  abscess  within  the 
gland.  It  can  be  detected  over  the  whole  area  of  the 
tumor,  and  is  not  bounded  by  an  indefinite  area  of 
harder  and  more  resisting  tissue.  The  pus  is  laudable 
and  of  normal  aspect,  and  contains  no  cheesy  frag- 
ments. If  the  aperture  be  enlarged,  a  diseased  gland 
will  be  seen  exposed  at  the  bottom  of  the  abscess  cav- 
ity. This  cavity  as  a  rule  will  not  close  until  the  gland 
has  been  more  or  less  entirely  destroyed  by  natural  or 
artificial  means. 

In  actual  practice  the  distinctions  between  these  two 


SCROFULOUS   LYMPHATIC   GLANDS.  1 53 

kinds  of  abscess  are  often  much  obscured.  Sometimes 
the  two  forms  are  combined  in  one  case,  and  often  the 
gland  abscess  proper  is  associated  with  much  inflamma- 
tory change  in  the  parts  around,  even  although  that 
change  may  not  lapse  into  actual  suppuration. 

Not  uncommonly  the  skin  sloughs  over  the  suppur- 
ating gland,  and  this  obstruction  may  be  extensive.  A 
very  usual  complication  is  the  undermining  of  the  skin 
before  the  pus  has  found  an  exit.  This  leads  to  trouble- 
some sinuses  and  intractable  ulcers.  The  undermined 
skin  about  the  oriffice  of  the  abscess  cavity  is  thinned, 
purplish,  and  of  poor  vitality.  Where  it  joins  healthier 
parts  a  tubercular  process  will  often  extend  in  the  sub- 
cutaneous tissues  and  add  daily  to  the  mischief.  This 
mode  of  extension  is  identical  with  that  observed  in 
the  walls  of  a  cold  abscess.  In  nearly  all  cases  there  is 
a  tendency  for  the  opening  to  become  fistulous  if  the 
pus  has  been  allowed  to  find  an  exit  for  itself,  and  very 
often  there  are  several  of  such  fistulous  apertures. 
These  sinuses  and  these  ulcers  with  undermined  edges 
are  apt  to  become  very  intractable,  and  give  trouble  for 
an  indefinite  period.  Some  of  the  worst  cases  I  have 
seen  have  been  in  adults.  Sometimes  these  glandular 
abscesses  reach  the  surface  with  a  remarkable  abscence 
of  inflammatory  symptoms,  and  may  often  be  classed 
with  the  most  frigid  of  cold  abscesses.  Very  often 
when  one  gland  has  suppurated  and  been  thus  eradi- 
cated, another  will  come  forward  and  repeat  the  pro- 
cess, which  may  thus  be  prolonged,  almost  indefinitely. 
These  gland  cases  afford  many  examples  of  what  Sir 
James  Paget  has  termed  "residual  abscess,"  that  is  to 
say,  an  abscess  occurring  from  the  remains  or  residues 
of  a  previous  supperative  process.  A  gland  suppurates, 
and  before,  perhaps,  all  the  disease  has  been  eliminated, 
the  process  ends,  the  materials  dry  up,  and  the  sinus 
closes.  The  case  may  appear  one  of  cure,  and  for 
months  or  years  the  part  may  seem  entirely  sound. 
Then,  probably  from  some  defect  in  health,  an  abscess 
will  appear  in  the  old  spot,  and  there  is  every  reason  to 
believe  that  it  has  arisen  from  the  residues  of  the  prev- 
ious trouble.     Often,  too,  I  believe  purulent  collections 


154  SYMPTOMS  AND   DIAGNOSIS   OF 

within  glands  dry  up  and  remain  quiet  for  indefinite 
periods,  then  a  residual  abscess  forms,  and  the  matter  is 
discharged  through  the  skin. 

Scars. — The  cicatrices  left  after  the  healing  of  sup- 
purating glands  and  the  closure  of  old  sinuses  and 
ulcers  are  often  very  conspicuous.  In  the  neck  especi- 
ally are  these  scars  apt  to  produce  much  disfigurement, 
and  to  form  a  permanent  evidence  of  the  scrofulous 
disposition  in  a  person,  They  vary  greatly  in  appear- 
ance. In  some  cases  a  number  of  nipple-like  processes 
or  minute  pedicles  of  skin  are  attached  to  the  scar.  In 
other  cases,  the  cicatrix  is  marked  by  bars  or  ridges  of 
altered  skin  that  are  unpleasantly  conspicuous.  These 
ridges  are  generally  covered  with  a  very  thin,  shining, 
purplish  integument,  like  purple  tissue  paper.  This 
delicate  covering  is  usual  in  scrofulous  scars,  and 
especially  in  those  of  recent  date.  Other  scars  are 
indented  and  corrugated,  or  show  evidence  of  much 
contraction,  and  thus  resemble  the  cicatrix  of  a  small 
but  deep  burn.  Very  often  the  altered  tissue  is  firmly 
adherent  to  the  deeper  parts,  and  the  cicatrix  becomes 
thereby  depressed ;  and  in  some  cases  this  depression  is 
very  conspicuous.  The  color  of  the  scar  tissue  is  usually 
different  from  that  of  the  surrounding  parts.  This  dif- 
ference is  marked  in  recent  cases,  and,  although  it 
becomes  less  pronounced  in  time,  may  always  be 
obvious.  The  color  is  that  of  a  dusky  red  or  purple. 
On  exposure  to  cold  the  purple  tint  becomes  greatly 
exaggerated,  and  the  least  excitement  or  unwonted 
exercise  will  intensify  the  red  blush  in  the  scar.  In 
warm  weather  these  scars  will  freqnently  appear  very 
conspicuously  red.  In  many  cases  they  are  very  sensi- 
tive and  tender,  and  remain  so  for  years,  the  condition 
varying  often  according  to  the  state  of  the  patient's 
health.  Sometimes  a  part  of  the  scar  will  give  way 
and  some  discharge  of  pus  take  place,  or  it  may  become 
the  seat  of  ulceration,  or  the  thin  cuticle  having  given 
way  it  may  exude  a  thin  serous  discharge.  These  com- 
plications as  a  rule  are  coincident  with  some  defect  in 
the  general  condition  of  the  patient.  As  years  pass  on 
the  scar  may  become  somewhat  less  conspicuous,  chiefly 


SCROFULOUS   LYMPHATIC   GLANDS.  1 55 

by  its  losing  some  of  its  unnatural  color,  and  assuming 
more  the  tint  of  the  adjacent  skin.  Its  more  promin- 
ent parts,  its  bars  and  ridges,  may  atrophy,  and  so 
another  source  of  disfigurement  be  removed  ;  it  may 
also  become  less  adherent  than  it  was  in  the  first 
instance,  and  drag  less  upon  the  parts  around.  Traces 
of  it  will,  however,  persist  until  the  last  days  of  the 
patient's  life. 

Pressure  effects. — Instances  of  injurious  compression 
upon  neighboring  structures  are  more  often  afforded  by 
the  mediastinal  glands  than  by  any  others.  One  of 
the  commonest  ill-results  of  such  compression  is  a  per- 
foration of  the  trachea,  as  a  rule  about  its  bifurcation.* 
Examples  of  injurious  pressure  effects  are  not  often 
afforded  by  the  external  glands,  and  such  examples  as 
there  are  have  for  the  most  occurred  in  the  cervical 
region.  Among  the  most  frequent  structures  to  be 
pressed  upon  are  the  jugular  veins.  In  such  cases  the 
face  may  look  bloated  and  purplish  as  if  from  extreme 
cold,  and  this  aspect,  combined  with  the  large  neck  full 
of  gland  tumors,  gives  the  patient  a  very  "  apoplectic 
appearance,"  if  one  might  be  allowed  to  accept  the 
conventional  idea  of  the  aspect  of  those  disposed  to 
immediate  apoplexy.  Dr.  Deligny  states  that  cerebral 
hyperaemia  may  be  produced  by  this  pressure  on  the 
veins.f  I  have  notes  of  several  cases  of  severe 
epistaxsis  in  connection  with  cervical  gland  disease. 
In  one  or  two  instances,  the  relation  between  the 
bleeding  and  the  gland  tumors  is  obvious,  and  I  imagine 
that  the  connection  between  the  two  depends  upon 
pressure  on  the  venous  trunks.  I  might  cite  the  fol- 
lowing example  that  occurred  in  one  of  my  out-patients 
at  the  London  Hospital : — 

A  girl,  aged  16,  had  a  considerable  number  of 
enlarged  glands  in  both  sides  of  her  neck.  She  pre- 
sented the  so-called  phlegmatic  type  of  struma.     These 


*  See  case  recorded  by  Dr.  H.  Thompson.  Clinical  Lectures.  Lon- 
don, 1880,  p.  39.  And  another  by  Mr.  Edwardes.  Med.  Chir.  Trans., 
vol.  xxxvii.  1854,  p.  151. 

f  "  Loc.  cit.,"  p.  78. 


156  SYMPTOMS   AND   DIAGNOSIS   OF 

glands  were  first  observed  two  years  ago,  and  appeared 
after  an  attack  of  scarlet  fever.  They  had  already  sup- 
purated, and  when  I  saw  her  there  were  old  scars  on 
both  sides,  and  three  open  sinuses  on  the  right  side  of 
the  neck.  For  the  last  twelve  months  she  had  been 
troubled  with  epistaxis.  Her  nose  would  often  bleed 
three  times  a  week,  and  then  perhaps  there  would  be  no 
haemorrhage  for  two  or  three  months.  The  epistaxis 
was  always  severe  when  the  gland  tumors  were  at  their 
largest,  i.  e.  just  before  they  suppurated.  As  soon  as 
they  had  broken,  the  patient  was  for  a  while  free  from 
any  attacks  of  haemorrhage.  She  had  menstruated  reg- 
ularly. 

Dr.  Deligny  asserts  that  the  carotid  vessels  may  be 
so  compressed  as  to  produce  cerebral  anaemia  or  even 
ulceration  of  the  wall  of  the  vessel.  He  also  gives 
references  to  cases  of  injurious  pressure  upon  the  sym- 
pathetic nerve  trunk  and  upon  the  vagus  nerve. 
Examples  of  pressure  upon  the  former  nerve  are  not 
uncommon.  In  not  a  few  instances  the  recurrent  lary- 
ngeal nerve  has  been  so  compressed  as  to  have  its  func- 
tion interfered  with.  Several  cases  have  been  noted  of 
pressure  upon  the  trachea  and  larynx  producing  alarm- 
ing results.  Mr.  Cooper  Forster  *  gives  a  drawing  of  a 
case  of  immense  gland  disease  in  the  neck  of  a  child 
aged  five.  The  patient  died  of  suffocation.  David 
Craigie  f  gives  a  case  from  Bleuland  of  an  infant  whose 
deglutition  was  impeded  by  the  pressure  of  enlarged 
glands  upon  the  gullet. 

Leucocythaemia  is  very  rare  in  strumous  gland  cases. 
I  believe  that  it  only  occurs  in  instances  of  rapid 
enlargement  of  many  glands,  and  may  be  present  to 
some  trifling  extent  in  the  first  stage  of  other  cases. 
Although  the  glands  are  crammed  with  leucocytes 
these  do  not  pass  in  any  numbers  into  the  general  cir- 
culation. This  fact  can  be  established  by  a  microscopic 
examination  of  the  efferent  vessels  of  the  gland  as  they 


*  Surgical  Diseases  of  Children,  p.  101. 

f  Elements  of  General  and  Pathological   Anatomy,   1848,  2nd  ed.  p. 
287. 


SCROFULOUS   LYMPHATIC   GLANDS.  l$y 

leave  that  body  at  the  hilus.  In  the  earliest  stages  of 
the  disease  sections  of  these  vessels  show  certainly  that 
they  contain  many  lymph  corpuscles,  and  probably  in 
some  cases  a  greater  number  than  in  health.  But  in 
more  advanced  cases  of  the  disease,  especially  when 
the  stage  of  caseation  has  been  reached,  the  efferent 
vessels  are  found  almost  empty  or  presenting  but  a  very 
few  leucocytes  among  the  coagulum  that  may  partially 
occupy  their  lumen.  This  obstruction  to  the  passage 
of  lymph  may  be  explained  by  the  early  occlusion  of 
the  medullary  sinuses.     (See  Chapter  XII.) 

In  Chapter  XII.  will  also  be  found  an  occount  of 
the  manner  in  which  gland  affections  spread. 

Dr.  Craigie,  in  the  work  just  alluded  to,  describes 
what  he  terms  a  "  strumous  mortified  bubo."  This 
consists  in  a  sudden  enlargement  of  the  "  glands  at  the 
bend  of  the  arm."  The  skin  over  them  soon  gives  way 
by  sloughing,  and  a  deep,  foul  sore  forms,  with  sharp 
cut,  irregular  edges.  At  the  bottom  of  this  hole  is  the 
diseased  gland.  After  the  destruction  of  the  gland  and 
much  sloughing  the  part  heals.  Cruikshank  observes, 
"  I  have  known  the  last-mentioned  glands  (the  brachial) 
die  and  slough  out  in  scrofula  without  any  great  incon- 
venience."* A  "  syphilitic-strumous  bubo  "  is  described 
by  Fournier  as  a  scrofulous  degeneration  of  a  gland 
already  affected  with  syphilis.  He  says  it  is  not 
uncommon  in  cases  where  syphilis  has  attacked  a 
strumous  person,  and  is  most  often  observed  in  the 
groin,  although  it  may  appear  in  any  part.f 

Diagnosis. — From  the  account  already  given  of  these 
gland  tumors  little  has  to  be  added  under  the  heading  of 
Diagnosis.  Strumous  disease  in  glands  may  be  mis- 
taken for  simple  and  syphilitic  bubo,  and  for  the 
tumors  that  characterize  Hodgkin's  disease  (the 
malignant  lymphoma  of  Billroth,  and  the  lymphosarcoma 
of  Virchow).  Among  the  other  affections  that  have 
been  named  in  connection  with  the  differential  diagnosis 
of  strumous  glands  are  various  solid  and  cystic  tumors, 
and  the  manifestations  of  glanders  and  farcy. 

*  Anatomy  of  the  Absorbing  Vessels.     London,  1790. 

f  Nouveau  Diet,  de  Med.  et  Chir.  Prat.     Art.   "  Bubon." 


158  SYMPTOMS  AND   DIAGNOSIS   OF 

The  chief  points  in  the  diagnosis  of  the  scrofulous 
tumor  are  these  : — The  age  of  the  patient  (most  often 
in  children),  the  site  of  the  mass  (most  often  in  the 
neck),  the  history  of  the  patient,  the  existence  possibly 
of  other  strumous  disorders,  or  the  evidences  of  past 
outcomes  of  the  disease,  the  indolence  of  the  affection, 
its  trifling  exciting  cause,  its  persistence,  and  its  tend- 
ency to  caseation  and  the  formation  of  pus.  The 
diagnosis  between  scrofula  and  the  earliest  stages  of 
Hodgkin's  disease  is  often  difficult,  often  for  a  while 
impossible.  The  main  elements  in  differentiating 
between  the  two  affections  are  these.  In  Hodgkin's 
disease  the  enlargement  is  rapid,  the  affection  spreads 
with  marked  persistence,  several  sets  of  glands  in  vari- 
ous parts  of  the  body  may  be  simultaneously  attacked, 
and  there  is  an  absence  of  periadenitis,  of  cheesy  degen- 
eration and  of  ready  suppuration.  In  Hodgkin's  dis- 
ease, moreover,  there  is  soon  to  be  noted  anaemia, 
emaciation,  muscular  debility,  and  a  general  and  rapid 
failing  in  health.  It  would  be  impossible  within  the 
limits  of  this  chapter  to  attempt  to  lay  down  the  differ- 
ential diagnosis  between  scrofulous  gland  tumors  and 
various  other  growths,  solid  and  cystic.  Such  diagnoses 
depend  upon  general  principles,  and  open  up  too  wide 
an  area  in  surgery  to  be  entertained  in  this  place.  As 
a  matter  of  fact,  if  Hodgkin's  disease  be  excluded,  the 
diagnosis  of  a  scrofulous  gland  is  in  ninety-nine  cases 
out  of  a  hundred  a  very  simple  object  to  be  attained. 


CHAPTER   XIV. 

THE  TREATMENT  OF  SCROFULOUS  LYMPHATIC  GLANDS. 

General  Measures. — It  is  needless  to  observe  that 
before  any  local  treatment  is  adopted  for  the  relief  of 
scrofulous  gland  disease  general  measures  for  cure  must 
be  made  use  of,  and  means  applied  for  the  improvement 


SCROFULOUS   LYMPHATIC   GLANDS.  1 59 

of  the  general  health  of  the  patient.  Scrofula  is  more 
than  a  merely  local  affection,  it  implies  a  serious  devia- 
tion from  the  normal  state,  and  expresses  itself  by  cer- 
tain tissue  defects  that  are  by  no  means  limited  to  any 
one  part  of  the  organism.  It  must  be  confessed  that 
these  general  measures,  which  involve  some  of  the  most 
elementary  factors  of  a  state  of  health,  are  often  seri- 
ously neglected,  and  not  infrequently  give  place  to 
some  favorite  local  plan  of  treatment. 

It  is  to  a  great  extent,  if  not  entirely,  useless  to  pre- 
scribe medicines  and  advise  applications  for  a  case  of 
gland  disease  if  the'  patient  on  leaving  the  prescriber 
returns  to  some  squalid  habitation,  where  he  will  be 
surrounded  with  the  very  conditions  that  have  caused 
and  maintained  his  disease.  In  many  instances,  the 
general  hygienic  measures  needful  for  the  proper  relief 
of  scrofulous  affections  cannot  be  fully  carried  out,  but 
that  is  no  reason  why  in  other  cases  those  measures 
should  be  neglected,  and  the  onus  of  a  cure  thrown 
upon  purely  local  modes  of  treatment.  It  is  the  merest 
truism  to  say  that  nothing  in  the  past  has  contributed 
more  to  the  lessening  of  strumous  diseases  than  has  the 
improvement  that  has  taken  place  in  the  hygienic  sur- 
roundings of  the  poor;  and  no  treatment  of  scrofula 
will  be  well  founded  unless  it  places  in  the  first  position 
a  regard  for  the  general  health  and  circumstances  of  the 
patient. 

The  first  indication  in  the  treatment  of  scrofula  is 
simply  this,  to  surround  the  patient  with  the  best  possi- 
ble hygienic  conditions.  These  conditions  would  com- 
prise plenty  of  fresh  air  and  light,  good  ventilation,  a 
generous  and  properly  regulated  diet,  suitable  clothing, 
exercise  in  the  open  air,  and  a  judicious  culture  of  the 
skin. 

I  am  aware  that  these  conditions  are  not  within  the 
reach  of  a  vast  number  of  the  scrofulous  poor,  but  for 
some  at  least  they  are  obtainable  in  various  charitable 
institutions. 

And  I  think  the  manner  in  which  some  of  these  val- 
uable institutions  are  made  use  of  is  a  strong  criticism 
upon  the  value  attached  by  many  to  general   hygienic 


l6o  THE   TREATMENT   OF 

measures  for  the  relief  of  scrofula.  What  kind  of  cases 
are  to  be  found  in  these  excellent  charities  ?  Cases  of 
incipient  disease  that,  commencing  in  some  city  slum, 
can  be  cut  short  by  sea  air,  good  food,  and  a  healthy 
dwelling  ?  Such  are  the  cases  that  should  be  found, 
but  they  are  very  rarely  to  be  met  with.  On  the  con- 
trary, the  bulk  of  the  cases  in  these  institutions  are 
examples  of  advanced  disease,  cases  that  are.  convales- 
cent from  a  grave  malady  rather  than  cases  where  that 
malady  is  being  warded  off.  If  the  importance  of  good 
hygiene  in  the  treatment  of  scrofula  were  only  more 
fully  recognized,  then  would  these  charities  be  available 
for  the  prevention  of  disease  rather  than  for  the  patch- 
ing up  of  advanced  cases  that  are  often  but  the  out- 
comes of  deferred  treatment. 

There  is  no  doubt  that  a  residence  at  the  sea-side  is 
of  infinite  value  in  a  large  number  of  cases  of  scrofula. 
As  it  may  be  supposed,  the  greatest  advantage  is 
observed  in  instances  of  acquired  struma,  in  cases  where 
the  disease  has  developed  in  the  purlieus  of  a  great 
town,  and  in  those  patients,  in  fact,  to  whom  sea  breezes 
and  our-door  exercise  offer  the  most  striking  possible 
contrast  to  their  previous  surroundings.  The  records 
of  the  Margate  Infirmary  for  scrofula  support  this  fact 
by  a  large  percentage  of  cases  of  cure,  and  by  a  still 
larger  number  where  a  very  considerable  improvement 
has  accrued.  Dr.  Deligny,  in  the  thesis  already  referred 
to,  enters  very  fully  into  the  question  of  the  value  of 
sea  air  in  scrofula  ;  and,  founding  his  conclusions  upon 
the  results  obtained  at  l'hopital  de  Berck,  speaks  enthu- 
siastically of  its  good  effects.* 

It  must  be  remembered,  however,  that  sea  air  is  not 
the  only  curative  element  in  the  sea-side  treatment. 
There  is  for  those  patients  who  are  not  confined  to  bed 
an  absolute  change  in  their  mode  of  living,  that  has  no 
slight  effect  in  any  good  result  that  follows. 

There  are  a  few  patients  (and  they  are  but  few)  whose 
condition  is  often  rendered  worse  rather  than  improved 


*  See  also  ' '  Rapport  sur  les  resultats  obtenus  dans  le  traitement  des 
enfants  scrofuleux  it  l'hopital  de  Berck-sur-mer.     Paris,   1866. 


SCROFULOUS   LYMPHATIC   GLANDS.  l6l 

by  a  residence  at  the  sea-side.  These  are  for  the  most 
part  certain  cases  with'  a  marked  phthisical  tendency, 
many  cases  of  eczema,  some  cases  of  strumous  ophthal- 
mia, and  here  and  there  a  case  of  lupus. 

Sea-water  baths  in  various  forms  and  bathing  in  the 
open  sea  are  valuable  therapeutic  agents  that,  however, 
require  some  discretion  in  their  use.  It  is  unnecessary 
to  detail  here  the  various  instructions  that  have  been 
laid  down  from  time  to  time  for  the  proper  administra- 
tions of  these  baths.  Such  instructions  are  for  the  most 
part  merely  the  expressions  of  common  sense  and  the 
outcomes  of  a  rudimentary  knowledge  of  medicine.  Dr. 
Deligny*  gives  an  excellent  account  of  the  chief  points 
in  connection  with  this  subject,  and  the  mode  of  con- 
ducting the  bathing  establishment  at  l'hopital  de  Berck 
may  be  well  taken  as  a  model. 

With  regard  to  the  general  medicinal  treatment  of 
scrofula,  I  think  it  may  be  said  that  there  are  few  dis- 
eases for  which  a  larger  number  of  remedies  and  specifics 
have  been  advised  and  used  than  have  been  used  in 
scrofula.  For  a  long  while  the  treatment  by  alkalies 
was  regarded  as  sovereign.  They  were  at  first  consid- 
ered to  act  by  neutralizing  the  acrid  matter  that  was 
the  foundation  of  all  strumous  disease,  and  on  the 
explosion  of  that  theory  it  was  asserted  that  they  were 
very  potent  in  dissolving  and  eliminating  tubercular 
deposits.  Mercury,  too,  was  for  some  time  a  specific  on 
account  of  its  supposed  solvent  action.  The  salts  of 
barium  were  for  many  years  held  in  great  esteem,  pro- 
bably from  the  fact  that  they  were  found  to  produce  no 
striking  evil  effects,  and  so  compared  favorably  with 
the  results  that  often  followed  when  mercury  was  freely 
administered.  A  French  therapeutistf  discovered  that 
arseniate  of  soda  was  a  cure  for  scrofula,  no  matter 
what  the  local  manifestation  (excepting  bone  disease). 
Dr.  Harkin,  of  Belfast,  asserted  that  in  chlorate  of 
potash  was  to  be  found  a  drug  of  remarkable  efficacy  in 
strumous  disease,  and  from  his  account  we  gather  that 


*  "  Loc.  cit.,"  p.  94. 

\  M.  Bouchet,     "  Bull,  dc  Therepeut.,"  vol.  lix.  p.  433. 
I  I 


1 62  THE   TREATMENT   OF 

"  fifteen  to  twenty  days  generally  suffice  to  heal  the 
most  extensive  ulcerations  of  the  cervical  and  submax- 
illary lymphatic  glands,"*  when  this  salt  is  administered. 

It  is  to  be  regretted  that  these  and  many  other 
highly  advised  remedies  have  not  proved  to  possess  the 
value  ascribed  to  them  by  those  who  recommended 
their  use.     . 

At  the  present  time  the  chief  drugs  used  in  the  treat- 
ment of  scrofula  are  cod-liver  oil,  iron,  iodine,  and 
certain  simple  tonics.  Cod-liver  oil  should  certainly 
occupy  the  first  place  in  this  list.  Its  use  is  often 
attended  with  remarkable  benefit,  and  it  seldom  fails  to 
effect  some  improvement  at  least  in  the  condition  of 
the  patient.  Before  this  drug  is  administered,  and, 
indeed,  before  any  prolonged  treatment  is  commenced, 
it  is  essential  that  the  digestive  functions  should  be  in 
good  order.  If  any  of  the  digestive  troubles  exist 
that  are  so  common  in  the  strumous,  they  may  be  best 
managed  by  an  occasional  aperient  of  calomel,  and  the 
use  of  a  mixture  composed  of  soda,  rhubarb,  with 
calumba,  gentian,  or  cinchona  bark.  At  the  same  time 
the  patient's  appetite  should  be  regulated  to  meet  the 
needs  of  the  case.  The  oil  should  be  given  for  a  long 
period  and  in  full  doses.  It  must,  of  course,  be  imme- 
diately omitted  if  vomiting  or  diarrhoea  is  induced,  and 
may  be  left  off  or  taken  in  smaller  doses  during  very 
hot  weather.  The  best  time  for  its  administration  is 
about  half  an  hour  after  meals,  as  it  is  less  likely  to 
occasion  nausea  then  than  if  taken  on  an  empty 
stomach.  In  those  cases  where  the  drug  is  not  toler- 
ated butter  may  be  given  as  Trousseau  advises,  or  the 
mixture  of  butter  and  iodides  that  he  has  recom- 
mended, f 

Niemeyer  states,  with  a  good  deal  of  truth,  that  cod- 
liver  oil  acts  most  beneficially  in  the  sanguine  or  erethic 
form  of  scrofula,  but  it  is  certainly  not  contra-indicated 
"  in  the  fleshy,  bloated  patients  of  the  torpid  class,"  as 
Birch-Hirschfield  maintains.     The   observation  of  the 


*  Dublin  Quarterly  Journal  of Medical  Science.     November,  1861. 
f  "Clinical  Lectures."     Sydenham  Society,  vol.  v.  p.  91. 


SCROFULOUS   LYMPHATIC   GLANDS.  163 

latter  author  that  "  on  glandular  tumors  it  seems  to 
produce  no  effect  whatsoever/'*  is,  I  am  convinced, 
ill-founded,  I  have  seen  in  many  cases  the  most  striking 
improvement  take  place  in  gland  enlargements  during 
the  use  of  this  oil,  and  Grancherf  speaks  of  the  entire 
disappearance  of  such  masses  when  the  oil  alone  has 
been  given. 

With  regard  to  iodine,  its  use  has  been  extolled  by 
many,  especially  by  Lugol;  but  I  imagine  that  much 
less  faith  is  placed  in  its  efficacy  now  than  was  the  case 
when  it  was  first  extensively  used.  It  is  a  drug  often 
badly  borne  by  patients,  and  can  seldom  be  taken  for 
any  length  of  time.  It  appears  to  be  most  applicable 
to  chronic  cases  that  show  an  absence  of  any  inflamma- 
tory reaction,  and  often  does  good  in  very  large  gland- 
ular swellings  of  old  standing.  The  dose  of  pure 
iodine  usually  recommended  for  a*  child  is  from  g1,,  to  fo 
of  a  grain  three  times  a  day,  and  it  is  best  given  com- 
bined with  one  grain  of  iodide  of  potassium.  I  think, 
however,  that  the  most  valuable  preparation  of  iodine 
is  the  syrup  of  the  iodide  of  iron,  and  I  think  I  have 
been  correct  in  ascribing  very  good  effects  to  this  drug 
in  many  instances,  especially  in  early  glandular  disease. 

Some  preparation  of  iron  is  generally  called  for  in 
cases  of  scrofula,  and  particularly,  of  course,  when  any 
anaemia  exists.  The  most  useful  drugs  would  appear 
to  be  the  saccharated  carbonate,  the  lactate  of  iron, 
dialysed  iron,  and  the  compound  syrup  of  the  phos- 
phate of  iron.  Any  of  these  forms  are  well  taken  by 
children,  and  the  last-named  preparation  can  be  very 
conveniently  combined  with  cod-liver  oil.  Some  simple 
tonic  is  of  service  in  many  strumous  cases,  and  quinine 
or  some  preparation  of  bark  is  certainly  the  best  to 
make  use  of,  especially  in  cases  where  suppuration  is 
active. 

It  is  needless  to  observe  that  a  vast  number  of  min- 
eral waters,  from  sea-water  downwards,  have  been 
advised   as  serviceable  in  scrofula.     One  of  the    best 


*  "  I.oc.  cit.,"  p.  32c. 

f  "  Loc  cit.,  Diet.  Encycl.,"  p.  341. 


164  THE   TREATMENT   OF 

would  appear  to  be  the  Adelheid  spring  of  Heilbronn, 
and  much  has  been  said  in  praise  of  the  waters  of 
Kreuznach,  Nanheim,  La  Bourboule,  etc. 

Local  measures. — These  may  be  considered  under 
two  heads,  viz.,  medicinal  treatment  and  operative 
measures. 

1.  Medicinal  treatment. — In  treating  any  cases  of 
gland  disease,  the  first  indication  is  to  remove  all 
sources  of  peripheral  irritation.  It  is  useless  to 
attempt  to  cure  a  glandular  enlargement  while  some 
lesion  of  the  surface  still  exists,  that  has  perhaps  not 
only  induced  the  tumor,  but  is  also  maintaining  it  and 
encouraging  its  increase. 

It  is  of  no  avail  to  apply  pigments  and  ointments  to 
enlarged  cervical  glands,  while  an  opthalmia  is  in  active 
progress  that  has  caused,  or  is  at  least  keeping  up  the 
lymphatic  mischief.*  It  is  useless  to  attempt  to 
diminish  a  glandular  tumor  in  the  axilla  that  has  been 
subsequent  to  ulcerating  chilblains,  if  those  skin 
affections  are  allowed  to  progress  unheeded.  In  many 
cases  the  surface  lesion  has  been  already  healed,  and 
there  is  no  peripheral  disturbance  that  can  account  for 
the  affection  of  the  lymphatics.  Some  circumstances, 
however,  must  not  be  too  readily  assumed  to  exist, 
and  in  every  instance  a  most  careful  examination  of 
all  parts  likely  to  be  concerned  must  be  carried  out. 
Particularly  should  the  mouth  and  pharnyx  be  exam- 
ined. Any  ulcers  may  be  treated  by  chlorate  of  potash 
or  by  some  caustic  or  astringent  application,  carious 
teeth  should  be  removed,  especial  attention  should  be 
directed  to  the  tonsils ;  and  in  any  case  where  those 
bodies  are  distinctly  enlarged  they  should  be  at  once 
excised.  The  condition  of  the  conjunctiva  and  of  the 
nasal  and  auditory  mucous  membrane  should  be  con- 
sidered, all  eruptions  of  the  skin  should  be  actively 
treated,  and  a  careful  examination  made  of  the  hairy 
scalp  for  any  sources  of  irritation,  It  must  also  be 
remembered  that  cervical  and  axillary  gland  disease 
may  depend — to  some  extent  at  least — upon  thoracic 
mischief ;  and  in  cases  where  the  clavicular  region  of 
the  neck  is  involved  this  should  be  borne  in  mind. 


SCROFULOUS   LYMPHATIC   GLANDS.  1 65 

With  regard  to  general  local  measures  the  part 
should  be  kept  as  free  from  irritation  as  possible,  and 
at  a  fairly  equable  temperature.  This  more  particu- 
larly applies  to  the  neck;  and  when  gland  disease  exists 
in  that  situation  the  part  should  be  kept  covered  up. 
All  handling  of  the  glands  should  be  avoided  as  much 
as  possible. 

I  might  here  speak  of  the  general  indications  with 
regard  to  suppuration  in  these  gland  tumors,  reserving, 
however,  the  detailed  consideration  of  abscess  for  a 
subsequent  paragraph.  I  think  it  may  be  laid  down  as 
a  rule  that  suppuration  should  not  be  encouraged  until 
the  pus  has  a  free  exit.  To  allow  a  large  purulent  col- 
lection to  form  is,  to  my  mind,  an  evidence  of  bad 
practice.  In  speaking  of  gland  abscesses,  I  shall  ven- 
ture to  strongly  maintain  the  value  of  the  earliest  pos- 
sible evacuation  of  pus.  No  measures  should  be  adopted 
in  any  case  that  would  tend  to  increase  suppuration 
before  there  is  an  exit  for  it,  but  when  there  is  a  free 
exit  for  the  pus  then  by  all  means  let  suppuration  be 
encouraged  as  much  as  possible.  I  mention  these  mat- 
ters as  an  introduction  to  the  question  of  poulticing. 
Poultices  are  often  applied  to  gland  enlargements  in  a 
very  casual  and  indiscriminate  manner.  I  would  say 
that,  with  scarcely  any  exception,  poultices  should  not 
be  applied  to  gland  tumors  unless  the  skin  has  yielded 
or  been  punctured,  and  there  is  thereby  a  free  opening 
for  the  discharge  encouraged  by  the  poultice.  The 
poulticing  of  inflamed  gland  masses  while  the  skin  is 
still  intact  merely  encourages  a  large  collection  of  pus 
beneath  the  integument  that  allows  a  large  abscess  cav- 
ity to  form,  and  is  very  apt  to  be  attended  by  consid- 
erable undermining. 

If  pus  must  form  let  steps  betaken  that  the  collection 
be  as  small  as  possible  by  the  time  the  matter  is  de- 
tected and  let  out.  For  these  reasons,  therefore,  I  think 
that  the  indiscriminate  use  of  poultices  in  strumous 
gland  affections  is  to  be  condemned.  There  is  another 
general  point  that  bears  upon  this  matter,  and  it  is  this. 
Occasionally  the  inflammatory  process  in  these  glands, 
or  rather  in  the  tissues  about  them,  is  somewhat  active, 


1 66  THE   TREATMENT   OF 

the  parts  become  tender,  the  skin  hot  and  perhaps  a 
little  red,  and  yet  there  is  no  certain  indication  of  the 
presence  of  any  pus.  In  such  cases  cold  evaporating 
lotions  are  to  be  advised.  Under  their  use  the  inflam- 
mation commonly  subsides,  and  as  the  swelling  of  the 
parts  becomes  less  marked,  fluctuation  at  one  spot  can 
perhaps  be  detected.  In  some  cases  of  this  character 
that  I  have  seen  suppuration  would  appear  to  have 
been  entirely  warded  off  by  active  treatment ;  and 
with  the  subsidence  of  the  acuter  symptoms,  the  gland 
tumor  was  found  to  have  actually  diminished  in  size. 

With  regard  to  local  applications,  the  first  drug  to  be 
considered  is  iodine.  Not  long  ago  iodine  in  the  form 
eiher  of  pigment  or  ointment  was  used  very  extensively 
as  an  application  for  gland  tumors. 

Glandular  enlargements  of  all  kinds  and  in  all  shapes 
were  indiscriminately  painted  over  with  iodine,  and 
that  having  been  done  the  local  treatment  was  consid- 
ered to  be  at  an  end.  It  would  appear  now  that  a 
great  change  of  opinion  has  taken  place  upon  this 
question,  and  many  surgeons  now  discard  the  iodine 
paint  and  iodine  ointment  altogether,  and  condemn 
them  as  useless. 

Perhaps  the  truth  lies  mid-way  between  these  modes 
of  practice.  The  local  effects  of  iodine  would  appear 
to  be  those  of  a  stimulant  or  irritant,  and  any  good 
that  it  accomplishes  is  due,  I  imagine,  to  the  increased 
blood  supply  that  it  encourages  in  the  part.  Thus  it 
will  be  found  that  applications  of  iodine  paint  do  posi- 
tive harm  in  cases  of  commencing  gland  disease,  and  in 
all  instances  where  inflammatory  processes  are  active. 
That  is  to  say,  the  drug  adds  to  the  mischief  and  inten- 
sifies it. 

But  although  it  may  be  injurious  in  these  instances 
it  is  not  injurious  in  all.  There  are  some  few  gland 
enlargements  that  are  benefited  by  iodine  applications. 
These  are  very  chronic  gland  tumors  that  have  assumed 
a  most  indolent  course,  or  have  come  absolutely  to  a 
standstill.  The  effect  of  iodine  upon  these  masses 
varies  according  to  the  condition  of  the  tumor,  but  in 
all  cases  the  effect  depends  upon  an  improved  blood 


SCROFULOUS   LYMPHATIC   GLANDS.  167 

supply.  If  the  morbid  change  is  not  very  far  advanced 
this  stimulus  may  serve  to  promote  resolution,  especially 
in  children,  but  if  suppuration  has  commenced  and  is 
remaining  for  a  time  in  abeyance,  the  iodine  may  act 
in  encouraging  the  process.  This  latter  object  is  seldom 
to  be  desired  except  in  certain  gland  enlargements  in 
adults,  when  any  hope  of  cure  other  than  by  suppura- 
tion may  reasonably  be  abandoned.  On  the  whole,  the 
use  of  the  stronger  preparations  of  iodine  is  seldom 
called  for,  and  is  mostly  limited  to  gland  disease  in 
adults. 

The  most  efficient  application  for  these  affections,  so 
far  as  I  am  aware,  is  the  unguentum  plumbi  iodidi. 
How  this  preparation  acts  I  cannot  say,  but  I  feel  as 
confident  of  its  good  effects  in  many  cases  as  one  can 
be  in  any  instance  where  more  than  one  mode  of  treat- 
ment is  being  simultaneously  carried  out.  The  oint- 
ment should  be  gently  rubbed  into  the  part  for  some 
five  minutes  night  and  morning.  It  is  not  to  be  advised 
in  any  cases  that  show  distinct  evidences  of  somewhat 
active  inflammation,  nor  in  cases  where  suppuration 
threatens,  nor,  on  the  other  hand,  in  cases  of  very 
recent  date.  Allowing  these  exceptions,  it  will  be 
found  that  the  application  is  useful  in  a  large  number 
of  cases,  and  especially  if  the  patients  are  children. 
In  adults  I  doubt  if  it  is  of  much  effect.  In  the  case 
of  any  supposed  improvement  from  the  use  of  this  or 
other  preparations,  it  must  be  borne  in  mind  that  many 
gland  cases  in  children  show  a  great  disposition  to 
spontaneous  cure,  whereas  in  adults  the  prognosis  is  not 
so  favorable.  Lugol  and  Bazin  strongly  recommend 
an  ointment  composed  of  iodine,  iodide  of  potassium, 
and  lard,  but  I  have  no  experience  of  its  use. 

Operative  measures. — Presuming  that  general  and 
local  remedies  have  been  made  use  of  without  avail, 
there  are  some  cases  that  will  be  specified  below  where 
an  operation  of.  some  kind  may  be  entertained.  The 
operative  measures  that  are  the  most  to  be  recom- 
mended are  excision,  scooping,  and  cautery-puncture. 

Excision. — This  plan  of  treatment,  which  consists 
simply  in  making  an  incision  over  the  gland  mass  and 


1 68  THE   TREATMENT   OF 

enucleating  it  from  its  bed,  is  of  somewhat  limited 
application.  In  any  case  the  operation  should  be  re- 
garded as  the  last  resource,  especially  in  children  in 
whom,  as  has  been  already  stated,  resolution  is  not 
uncommon.  In  the  case  of  adults  the  operation  may 
be  more  readily  undertaken,  provided  that  the  local 
conditions  be  such  as  permit  the  operation.  I  think 
that  the  operation  is  applicable  to  three  kinds  of  case. 
i.  There  is  only  one,  or  at  the  most  only  two  or  three 
gland  tumors.  These  are  perfectly  indolent,  and  have 
resisted  all  general  treatment.  There  is  an  absence  of 
any  signs  of  active  inflammation.  The  gland  tumor  is 
of  fair  size,  is  superficial,  is  throughout  of  equal  density 
to  the  touch,  and  is  freely  moveable.  I  have  met  with 
several  instances  of  gland  disease  of  this  character  in 
children,  and  have  removed  the  tumor  (or  in  some  cases 
more  than  one)  in  the  out-patient  room,  and  allowed 
the  child  to  go  home.  The  results  have  so  far  been 
most  satisfactory.  These  masses  after  removal  are 
generally  found  to  be  more  or  less  caseous,  but  to  pre- 
sent no  purulent  collections.  2.  There  are  a  large 
number  of  glands  that  have  increased  without  any 
symptoms,  and  that  have  always  been  free  from  pain 
and  without  tenderness.  Some  might  be  large,  and 
lobulated  masses  might  be  constituted,  but  in  any 
instance  the  glands  are  freely  moveable,  and  in  the  case 
of  the  lobulated  tumors  the  individual  glands  forming 
those  masses  can  be  clearly  made  out.  There  are,  in- 
deed, no  adhesions  of  any  kind.  These  masses  should 
be  well  limited,  and  clear  of  any  more  general  but  less 
defined  gland  disease  in  the  vicinity.  Such  tumors  are 
most  common  at  the  base  of  the  neck  and  in  the  axilla, 
and  if  left  alone  are  apt  to  assume  very  grave  dimen- 
sions before  they  suppurate.  They  shell  out  with 
remarkable  ease  when  operated  upon,  and  I  have  on 
more  than  one  occasion  seen  a  porringer  full  of  them 
turned  out  of  the  axilla.  Microscopic  examination 
shows  them  to  be  as  a  rule  glands  that  I  have  described 
in  the  second  division  in  the  chapter  on  the  histology 
of  the  disease.  Indeed,  one  was  taken  from  a  case 
where  an  enormous  number  of  glands  were  removed 


SCROFULOUS   LYMPHATIC   GLANDS.  169 

from  the  axilla  by  Mr.  Couper  at  the  London  Hospital. 
The  lad,  the  subject  of  the  operation,  did  very  well. 
3.  A  single  large  and  fairly  moveable  tumor  is  excercis- 
ing  injurious  pressure  upon  some  neighboring  part. 
Or  such  pressure  is  caused  by  a  fairly  moveable  mass 
composed  of  several  glands  that  all  together  do  not 
form  a  tumor  too  large  to  be  readily  removed.  Such 
cases  are  very  uncommon,  although  instances  are 
recorded  of  injurious  compression  effected  by  compara- 
tively small  and  isolated  gland  tumors.  The  bulk  of 
cases  where  evil  pressure  effects  are  apparent  are  usually 
cases  of  very  large  and  deeply  adherent  glandular  masses 
that  are  totally  unsuitable  for  the  operation  of  excision. 

Before  disposing  of  this  subject  two  questions  remain 
to  be  considered.  A.  What  is  the  rationale  of  the 
operation  ?  and  B.  Is  the  operation  itself  a  simple  one  ? 

A.  In  the  first  two  instances  of  gland  disease  just 
given,  excision  is  to  be  advised  on  these  grounds.  The 
affection  has  proved  intractable  to  ordinary  treatment 
patiently  tried.  As  has  been  shown,  these  strumous 
glands  are  apt  to  spread  locally  and  to  infect  neighbor- 
ing glands,  and  by  their  timely  removal  such  a  mode  of 
extension  is  prevented.  In  the  class  of  case  No.  2,  this 
local  extension  is  very  evident,  and  is  apt  to  lead  to  a 
grave  form  of  scrofulous  tumor.  If  the  operation  is 
restricted  to  the  species  of  cases  mentioned,  there  is 
every  reason  to  suppose  that  the  local  disease  can  be 
entirely  eradicated.  If  such  eradication  is  effected,  a 
malady  is  cut  short  that  if  left  might  lead  to  prolonged 
evil  effects,  to  tedious  suppuration  with  all  its  probable 
ill  consequences.  The  gland  tumors  that  are  referred 
to  in  instance  No.  2  will  in  time,  if  left  alone,  become 
matted  together,  and  probably  lead  to  the  most  intracta- 
ble form  of  suppurating  strumous  glands.  The  clean 
and  simple  scar  left  after  the  operation  compares  favora- 
bly with  the  cicatrix  commonly  formed  when  extensive 
suppuration  has  existed.  Many  have  urged  the  opera- 
tion of  excision  on  the  grounds  that  by  the  removal  of 
caseous  masses  the  patient, is  rendered  less  liable  to  gen- 
eral tuberculosis.  I  think,  however,  that  this  argument 
maybe  entirely  discarded.     Even  if   it  be  allowed  that 


I70  THE   TREATMENT   OF 

general  tuberculisation  depends  upon  some  cheesy  focus 
it  must  be  admitted  that  out  of  the  enormous  number  of 
patients  who  present  caseous  deposits  in  their  bodies, 
the  percentage  of  those  who  fall  victims  to  diffused 
tubercular  disease  is  so  very  small  that  the  probability 
of  that  disease  may  be  put  out  of  the  question.  I  think 
also,  that  the  argument  advanced  by  Ruehle*  in  favor 
of  removing  glands  on  the  plea  that  such  removal  may 
prevent  phthisis,  is  also  unworthy  of  consideration  in 
discussing  this  mode  of  treatment.  One  word' as  to  the 
other  aspect  of  this  subject.  Excision  of  glands  has 
been  objected  to  on  the  ground  that  the  operation  if 
successful  is  apt  to  be  followed  by  a  fresh  outbreak  of 
scrofula  in  some  other  part.  What  has  been  already 
said  about  the  antagonism  between  strumous  diseases 
would  appear  to  support  this  proposition.  But  in  prac- 
tice no  such  evil  consequences  are  found  to  follow. 
Velpeau  has  very  rarely  seen  any  lung  troubles,  for 
example,  appear  after  these  operations,  and  Gosselin 
maintains  that  when  such  ill  results  do  follow  they  are 
due  to  an  enfeebling  of  the  patient  consequent  upon  an 
extensive  suppuration  after  the  operation,  f  I  have 
been  enabled  to  watch  for  long  periods  six  patients  who 
have  undergone  thismodeof  treatment,  and  in  none  of 
these  cases  did  any  fresh  scrofulous  disease  appear.  A 
sequence  of  scrofulous  affections,  is  commonly  met  with 
in  severe  forms  of  the  malady,  and  if  exception  be 
made  of  some  of  the  cases  that  come  under  the  second 
heading  it  will  be  observed  that  most  of  the  instances 
of  gland  disease  suitable  for  excision  are  not  among  the 
graver  examples  of  scrofula.  The  reasons  for  operating 
in  the  third  example  above  given  required  no  detailed 
mention. 

In  no  instance  where  a  proper  selection  of  case  was 
made  have  I  seen  fresh  glandular  troubles  arise  that 
could  be  ascribed  to  the  operation. 

B.  I  think  this  operation  may  be  regarded  as  a  sim- 
ple one  if  it  is  restricted  to  the  cases  mentioned.  There 

*  Loc.  cit. ,  Ziemssen's  Cyclop.,  vol.  v.  p.  605. 

f  Quoted  by  Humbert.     Des  Neoplasmes  des  ganglions  lymphatiqucs. 
Paris,  1878,  p.  138. 


SCROFULOUS   LYMPHATIC   GLANDS.  171 

are,  however,  certain  points  of  difficulty.  In  the  first 
place,  the  surgeon  may  be  very  much  deceived  as  to 
the  mobility  of  the  mass  he  proposes  to  excise.  A 
gland  that  feels  fairly  moveable  before  the  skin  is 
incised  may  be  found  very  adherent  to  the  deeper  parts 
when  its  removal  is  attempted.  For  the  operation  to 
be  a  satisfactory  one  the  tumor  should  be  loose  enough 
to  shell  out  easily  with  the  handle  of  a  scalpel  after 
a  few  touches  with  the  blade.  Anything  like  prolonged 
dissection  is  not  desirable,  and  a  violent  tearing  out  of 
glands  is  perhaps  as  bad.  Indeed  if  some  of  .these 
glands  are  roughly  handled  the  capsule  is  apt  to  give 
way  and  the  caseous  contents  to  escape,  thereby  still 
further  complicating  the  operation.  In  the  second 
place,  the  surgeon  may  be  deceived  as  to  the  number 
of  diseased  glands  he  is  about  to  remove.  Perhaps 
only  two  glands  are  conspicuous  before  the  operation, 
but  on  excision  these  others  are  discovered  ;  they  are 
removed,  and  more  glands  deeper  down  still  are 
encountered,  and  so  on.  In  such  cases  it  is  better  to  do 
too  little  than  too  much.  In  the  case  of  numerous  gland 
tumors  mentioned  under  the  second  heading  as  given 
above,  discretion  must  be  exercised  as  to  how  far  the 
operation  is  to  extend  whenever  it  is  found  that  the 
tumors  reach  down  among  the  deeper  parts.  In  these 
cases  however,  the  ease  with  which  the  masses  gener- 
ally shell  out  will  allow  of  them  being  safely  removed 
from  considerable  depths.  In  one  case  I  removed  a 
number  of  glands  from  behind  the  carotid  vessels,  the 
wound  was  dressed  antiseptically  and  did  well.  In 
removing  deeply  placed  glands  from  the  base  of  the 
neck  there  is  much  risk  of  injuring  the  dome  of  .the 
pleura,  to  which  structure  I  have  seen  these  glands  in 
more  than  one  instance  adherent.  In  operations  of  any 
magnitude  about  the  neck  there  is  of  course  the  usual 
risk  of  haemorrhage  and  the  possibility  of  an  entrance 
or  air  into  injured  veins.  Mr.  Holmes*  relates  the  case 
of  a  child  whose  axillary  artery  he  accidentally  wounded 

*  Surgical    Treatment   of  the   Diseases    of  Infancy   and  Chilaltood, 
London,  1868  p.  639. 


172  THE   TREATMENT   OF 

in  removing  some  gland-masses  from  the  armpit,  the 
tumors  being  adherent  to  that  vessel.  When  such  adhe- 
sions exist  it  can  be  understood  that  this  accident  is  by 
no  means  unlikely  to  occur,  even  under  the  hands  of  so 
experienced  a  surgeon  as  Mr.  Holmes.  The  vessel  in 
this  instance  was  ligatured  above  and  below  the  wound, 
and  the  case  did  well.  In  all  cases  where  the  wound  is 
large  or  deep,  it  is  well  that  it  be  dressed  throughout 
antiseptically  according  to  Lister's  method.  As  a  rule, 
healing  takes  place  readily  and  well  if  the  edges  of  the 
incision  have  been  carefully  approximated. 

Scooping. — This  plan  of  treatment  is  thus  carried 
out.  An  incision  about  a  quarter  of  an  inch  in  length 
is  made  in  the  skin  over  the  gland  to  be  operated  upon, 
and  is  then  continued  through  the  capsule  of  the  gland 
itself.  A  Volkmann's  "  spoon  "  is  then  inserted,  and 
the  contents  of  the  gland  scooped  out.  In  cases  where 
sinuses  exist  the  scoop  may  be  passed  through  one  of 
them,  provided  that  the  condition  of  the  gland  does 
not  forbid  the  operation. 

This  procedure  can  be  adopted  in  a  good  number  of 
cases  of  strumous  gland  disease.  It  is  not  applicable  to 
the  various  gland  affections  mentioned  as  suitable  for 
excision.  The  "  spoon "  should  not  be  used  for  any 
glands  that  are  freely  moveable,  or  that  are  of  recent 
date,  or  that  show  evidence  of  very  active  mischief. 
The  cases  to  which  it  may  be  most  advantageously 
applied  are  these :  glands  that  have  resisted  treatment 
and  are  of  long  standing,  that  have  attained  good  size, 
and  are  either  becoming  soft  or  are  distinctly  softened. 
Especially  is  it  important  that  these  tumors  should  be 
adherent,  and  none  are  better  suited  for  the  operation 
than  are  those  that  are  closely  adherent  to  the  skin. 
Such  glands  are  caseous  either^  wholly  or  in  part,  and 
present  larger  or  smaller  purulent  foci.  Some  of  these 
glandular  tumors  will  be  of  great  size,  and  made  up  of 
lobulated  masses  matted  together.  In  some  parts  of 
such  a  mass  suppuration  might  have  occurred  and 
sinuses  be  present ;  it  may  then  be  possible  to  attack 
the  glands  whose  capsules  are  still  intact  through  the 
medium  of  these  sinuses.   The  operation  should  not  be 


SCROFULOUS   LYMPHATIC   GLANDS.  1 73 

performed  upon  actively  inflamed  glands,  nor  upon 
glands  that  show  gross  evidences  of  suppuration.  If 
the  tumor  be  large  it  may  be  advisable  to  insert  the 
instrument  through  more  than  one  opening  in  the  skin. 
The  rationale  of  the  operation  is  very  simple.  The 
glands  operated  upon  are  of  a  kind  that  cannot  be 
expected  to  end  in  resolution.  Natural  processes  would 
in  time  throw  out  the  diseased  material,  but  such  elim- 
ination would  be  tedious,  and  attended  with  much  local 
disturbance,  even  if  it  made  no  impression  upon  the 
general  health.  There  would  be  prolonged  suppuration 
and  possibly  unsightly  scarring."  On  the  other  hand, 
the  operation  effects  in  a  few  minutes  what  natural 
processes  would  probably  require  months  to  bring 
about.  With  regard  to  the  operation  itself,  it  may  be 
considered  as  a  simple  one  if  the  cases  be  properly 
selected. 

If  the  "  spoon  "  be  applied  to  glands  that  are  freely 
moveable  under  the  skin,  the  loose  connective  tissue 
about  the  tumors  is  opened  up,  and  into  that  tissue 
some  of  the  morbid  products  of  the  gland  may  readily 
escape.  Thus  if  non-adherent  glands  are  operated  upon 
abscess  is  likely  to  form,  and  undermining  of  the  skin. 
and  other  evils  are  apt  to  follow.  It  happens  that  the 
glands  most  suitable  for  the  treatment  are  those  that 
have  usually  the  thickest  capsules,  and  thus  there  is 
little  risk  of  the  instrument  straying  beyond  the  tumor 
operated  on.  The  capsule  is  of  course  left  behind,  but 
it  gives  no  trouble,  and  probably  shrinks  into  a  harmless 
mass  of  fibrous  tissue.  It  must  be  remembered  that  its 
vascular  supply  is  often  considerable  when  compared 
with  that  of  the  gland  tissue  itself.  After  the  operation,- 
it  is  well  to  gently  syringe  out  the  cavity  with  a  weak 
carbolic  solution,  and  in  all  cases  the  operation  should 
be  performed  with  antiseptic  precautions.  If  a  large 
cavity  is  left,  a  drainage  tube  shoulds  be  inserted  and 
maintained  in  position  for  so  long  as  required.  I  have 
seen  very  good  results  follow  in  instances  where  no 
antiseptic  precautions  have  been  taken,  but  as  in  all  cases 
there  is  some  chance  of  opening  up  the  cellular  tissue  of 
the  neck,  those  precautions  had  better  not  be  neglected. 


174  THE   TREATMENT   OF 

Cautery  puncture  is  one  of  the  very  best  operative 
measures  at  the  disposal  of  the  surgeon  for  the  cure  of 
scrofulous  glands.  I  had  practised  it  myself  in  many 
cases  before  I  was  aware  that  it  had  been  advised  and 
used  with  success  by  certain  surgeons  in  France.  In 
this  operation  I  make  use  of  a  thermo-cautery  point 
about  as  thick  round  as  a  No.  7  catheter.  This  point, 
having  been  heated  to  a  bright-red  heat,  is  thrust  through 
the  skin  into  the  substance  of  the  gland,  and  passed  in 
three  or  four  directions  in  the  body  of  the  tumor  before 
it  is  removed.  If  the  gland  be  at  all  moveable  it  is 
necessary  that  it  should  be  firmly  fixed  with  the  thumb 
and  forefinger  while  the  cautery  is  being  applied.  If 
no  pus  or  cheesy  matter  follows  the  removal  of  the  iron 
a  simple  zinc  dressing  may  be  applied,  but  if  any  such 
matters  escape  then  a  poultice  should  be  ordered.  This 
simple  operation  is  applicable  to  a  large  number  of 
glandular  swellings.  It  may  be  used  in  any  of  the 
tumors  described  as  suitable  for  the  treatment  by  scoop- 
ing, and  in  any  of  the  tumors  placed  in  the  first  division 
of  the  cases  considered  proper  for  excision.  It  will 
thus  be  seen  that  it  is  applicable  to  a  larger  variety  of 
gland  masses  than  is  either  of  the  two  modes  of  opera- 
tion already  described.  I  consider  it  superior  to  the 
treatment  by  scooping,  and  it  is  certainly  much  more 
simple  and  much  more  easy  to  perform  than  is  that 
operation.  It  is  more  adapted  for  adherent  than  for 
moveable  glands,  and  should  not  be  practiced  upon 
tumors  that  are  less  in  size  than  a  large  cherry.  If  the 
gland  mass  contains  no  pus  and  no  caseous  matter  soft 
enough  to  escape,  little  or  no  discharge  follows  the 
puncture  ;  but  the  tumor,  after  a  temporary  enlarge- 
ment, begins  to  shrink,  and  soon  terminates  in  cure.  If 
any  pus  be  present  it  has  a  free  exit,  and  the  fact  of 
the  aperture  having  been  made  by  a  cautery,  insures  its 
remaining  patent  for  a  considerable  period. 

How  this  procedure  acts  when  it  cures  glands  that 
contain  neither  pus  nor  softened  cheesy  matter,  I  cannot 
say.  It  obviously  excites  a  healthier  action,  and  leads 
to  very  satisfactory  resolution. 

In  the  case  of  moveable  glands,  the  charring  of  the 


SCROFULOUS  LYMPHATIC  GLANDS.  1 75 

parts  that  occurs  along  the  line  traversed  by  the  cautery- 
would  appear  to  prevent  that  extension  of  mischief  into 
the  adjacent  cellular  tissue  that  is  apt  to  occur  when  a 
Volkmann's  "spoon  "  is  made  use  of. 

The  time  required  to  effect  a  cure  under  this  mode 
of  treatment  varies  according  to  the  size  and  condition 
of  the  gland  tumor.  In  cases  where  no  pus  or  caseous 
matter  escapes,  some  fourteen  or  twenty-one  days  are 
sufficient  to  bring  about  the  cure  of  the  mass,  the  punc- 
ture having  healed  a  long  while  before  that  time.  If 
there  be  much  pus  or  broken  down  material  in  the 
gland  a  longer  time  may  be  necessary,  although  many 
cases  end  favorably  within  the  period.  In  one  or  two 
instances  a  very  rapid  resolution  took  place.  I  have 
tried  this  simple  operation  some  twenty  times,  in  all 
cases  in  children,  and  the  results  have  been  extremely 
satisfactory.  In  only  one  instance  did  the  skin  become 
undermined,  and  then  the  mischief  was  but  of  limited 
extent.  The  scar  left  is  simple,  small,  and  in  way 
conspicuous.* 

The  operative  measures  now  to  be  briefly  alluded  to 
are,  I  think,  of  but  little  practical  value,  while  several 
of  them  have  already  been  abandoned  as  useless. 

Interstitial  Injections. — This  plan  of  treatment  was 
some  time  ago  extensively  carried  out  on  the  Continent, 
but  I  believe  it  is  made  much  less  use  of  at  the  present 
time.  A  Pravaz's  syringe  is  used,  and  the  point  thrust 
well  into  the  interior  of  the  gland,  the  material  to  be 
injected  being  then  discharged,  A  vast  number  of  dif- 
ferent solutions  have  been  used,  and  amqng  them  may 
be  mentioned,  tincture  of  iodine,  alcohol,  chloride  of 
zinc,  pepsine  with  or  without  dilute  hydrochloric  acid, 
various  dilute  acids,  and  nitrate  of  silver.  Dr.  Morell 
Mackenzie!  appears  to  have  made  the  most  extensive 
use  of  this  treatment,  and  his  conclusions  may  be  sum- 
marised as  follows:  the  treatment  may  be  either  by  pro- 
moting resolution   of  the  gland,  or  its   destruction  by 

*  A  brief  notice  of  this  treatment,  with  cases  under  the  care  of  Dr. 
Perier  at  l'hopital  Saint-Antoine,  will  be  found  in  the  Journ.  de  Med.  et 
Chirurg.     Paris,  Jan.   1881,  p.  17. 

f  Med.  Times  and  Gazette,  vol.  i.  1875,  p.  577. 


174  THE   TREATMENT   OF 

Cauter       To  effect  the  former  end,  the  dilute  acetic 
measured       V.  is   used.     Five   to   twenty  drops  are 
scrofulous'-       ng  to  the  size  of  the  gland.     The  injec- 
cases  befc    JC  repeated  not  oftener  than  once  a  week, 
used  wit"  e.rage  duration  of   the    treatment    is    three 
this  ope     )  effect  destruction  of  the   tumor  three  to 
about  3      .  a  solution  of  nitrate  of  silver  (  3  j  to   3  j)  are 
havin  ''     Three  to  four  injections  are  usually  sufficient 
the  ''      \y  carry  out   this   treatment.     Out  of  twenty- 
thr<"     ases  treated   with  acetic  acid  fifteen  were  quite 
it'      .    nd  a  like   good   result  followed  in  three  out  of 
uve   cases    treated  with    the    silver  solution.     Dr. 
jkenzie   gives   no  details   as   to   the  proper  cases  to 
jet  for  these  very  different  modes  of  treatment. 
French  surgeons  for  the  most  part  recommend  iodine 
for  injections,  using   from  five  to  ten  drops  of  the  tinc- 
ture  for  each   application.     The   treatment  has  to   be 
repeated  some  five  or  six  times  in  each  case.* 

Seton. — This  treatment  is  applicable  to  large  indurated 
gland  tumors,  and  its  mode  of  cure  is  merely  by  effect- 
ing supuration  in  the  body,  and  thereby  bringing 
about  its  elimination.  It  must  be  owned,  however, 
that  there  are  better  curative  measures  at  the  surgeon's 
disposal. 

A  great  point  urged  by  those  who  favor  this  opera- 
tion is  that  it  leaves  very  little  scar.  A  seton  composed 
of  a  single  thread  of  silk  shonld  be  passed  through  the 
tumor  from  end  to  end  in  its  long  axis.  In  a  few  days 
the  gland  swells,  inflames,  and  becomes  painful.  About 
the  twelfth  or  fifteenth  day  it  softens,  and  by  the  twen- 
tieth or  twenty-fifth  day  suppuration  is  well  established 
(Deligny). 

Electricity  has  been  used  in  various  ways,  but  the 
accounts  of  its  value  are  somewhat  conflicting. 

The  remaining  modes  of  treatment  may,  I  think,  be 
discarded  as  useless,  if  not  as  actually  detrimental.  They 
comprise  crushing  the  gland  by  violent  compression 
between  the  thumb  and  fingers  through  the  uninjured 

*See  "  Des  Neoplasmes  des  ganglions  lymphatiques,"  by  Dr.  Hum- 
bert. Paris,  1878,  p.  137.  See  also  observations  and  case  by  Dr.  Mars- 
ton.      "  Bull  gen.  de  Therap  ."  1876. 


SCROFULOUS   LYMPHATIC   GLANDS.  tf]f 

skin.    The  capsule  ruptures  and  the  mass;-  if     '^     '         ,^ 

may  be  broken  up.     As  may  be  suppo?       _CUI  when  a 

puration   commonly  follows.     Then   tht 

ment  by  subcutaneous  laceration  of  the  gkUi    ji-  ■, 

means  of  a  cataract  needle  inserted  benea't1     "       j-,- 

and  lastly,   the   plan  of  treating:  these  glai' 

V  r     .  &  i         caseous 

continued  compression.  lK 

A  few  of   the  commoner  complications    of   . 
gland  disease  may  now  be  considered.  ^     Tf 

Gland  Abscess. — There  are  two  points  in  thY  "  .1 
ment  of  these  abscesses  upon  which  a  large  nul  1 
surgeons  are  agreed.  In  the  first  place,  the  puru.  ,^ 
collection  should  be  opened  as  soon  as  possible,  as  so-' 
indeed,  as  there  is  any  evidence  of  pus ;  and  seconds 
the  opening  made  for  the  evacuation  of  the  matter 
should  be  as  small  as  possible.  In  1871  the  editor  of* 
the  British  Medical  Journal  obtained  from  a  number  of' 
hospital  surgeons  expressions  as  to  their  opinions  about 
the  treatment  of  these  abscesses.  The  greater  number 
were  in  favor  of  early  incision  and  small  puncture.*  I 
can  conceive  of  no  valid  arguments  in  favor  of  the  prac- 
tice of  allowing  these  abscesses  to  break  spontaneously. 
By  such  practice  a  large  abscess  cavity  is  allowed  to 
form,  the  skin  becomes  extensively  undermined,  trouble- 
some sinuses  and  ulcers  usually  follow,  and  end  in 
unsightly  cicatrices.  Free  incisions  into  glandular 
abscesses  also  are  very  commonly  followed  by  like  ill 
results,  and  are  certainly  to  be  condemned.  With  regard, 
however,  to  abscesses  that  have  formed  in  the  connec- 
tive tissue  outside  a  gland,  the  capsule  of  which  is  still 
intact,  some  reservation  must  be  made.  These  collec- 
tions are  not  difficult  to  diagnose  from  those  within  the 
glands  by  means  of  the  signs  already  given.  At  the 
bottom  of  such  collections  a  diseased  gland  is  commonly 
to  be  seen,  and  until  this  body  has  been  removed,  either 
by  natural  or  artificial  means,  the  suppuration  is  likely 
to  continue.  It  is  well,  however,  to  make  a  rule  of 
opening  these  abscesses  by  a  small  puncture,  for  under 
such  treatment  the  case  may  do  well.     If  the  suppura- 

*  British  Medical  Journal,  vol.  ii.  1871,  p.  727,  et  seq. 


178  THE   TREATMENT   OF 

tion  continues  the  incision  can  at  any  time  be  enlarged, 
and  the  exposed  gland  treated.  It  is  rarely  advisable 
to  attempt  either  to  enucleate  this  body  from  its  bed 
or  to  dissect  it  out.  It  is  usually  very  adherent,  and 
the  adjacent  parts  much  inflamed.  The  best  plan  is  to 
thrust  a  point  of  the  thermo-cautery  into  the  gland,  and 
allow  it  to  shrink  or  to  discharge  its  contents.  I  think 
this  treatment  is  better  than  that  advised  of  destroying 
the  gland  with  potassa  fusa,  or  of  dusting  it  over  with 
the  red  oxide  of  mercury. 

As  to  the  best  mode  of  evacuating  gland  abscesses  it 
will  be  observed  that  most  of  the  plans  of  treatment 
recently  advocated  have  these  common  features — a 
small  opening,  and  no  handling  of  the  gland,  after  the 
pus  has  been  let  out.  Thus  Sir  James  Paget*  advised 
a  small  puncture  some  two  lines  in  length,  with  care  to 
avoid  any  pressure  upon  the  part.  Mr.  Lawson  Taitf 
went  a  step  further,  and  recommended  that  the  pus 
should  be  drawn  off  by  repeated  punctures  with  a  hypo- 
dermic syringe.  The  same  principle  underlies  Guersant's 
plan  of  evacuating  these  gland  abscesses  by  a  single 
seton  thread,  and  the  mode  of  treatment  also  advised 
by  some  of  puncturing  the  body  with  a  trocar. 

I  would,  however,  most  strongly  advise  that  these 
abscesses  should  be  opened  by  a  single  puncture  of  a 
fine  thermo-cautery  point. 

I  made  a  careful  trial  of  some  of  the  principal  meth- 
ods of  treatment  advised,  and  found  none  to  equal  the 
use  of  the  cautery.  The  operation  takes  but  a  moment, 
and  I  think  it  is  but  little  more  painful  than  incision 
with  a  knife.  As  the  pus  escapes  no  pressure  should 
be  exercised  upon  the  part,  but  the  matter  allowed  to 
spontaneously  trickle  out.  I  think  the  next  best  plan 
of  opening  these  abscesses  is  by  a  small  puncture  with 
a  tenotome,  and  subsequent  drainage  with  a  small 
india-rubber  tube. 

Dr.  Sydney  Ringer;}:  has  strongly  advocated  the  use 
of  the  sulphides  of  potassium,  sodium,  or  calcium  in 

*  Med.  Times  and  Gazette,  vol.  i.  1856,  p.  5. 
\  British  Medical  Journal,  vol.   i.  1871,  p.  117. 
%  Lancet,  vol.  i.  1874,  p.  264. 


SCROFULOUS   LYMPHATIC   GLANDS.  1 79 

cases  of  glandular  abscess.  He  asserts  that  these  drugs 
often  appear  to  arrest  suppuration,  or  when  pus  has 
formed  they  hasten  the  maturation  of  the  abscess, 
render  it  more  circumscribed,  and  promote  a  healthy- 
condition  of  the  discharges.  For  children  he  advises 
from  TV  to  ^  grain  or  a  grain  of  the  sulphide  of  calcium 
every  two  or  three  hours. 

Sinuses  are  apt  to  follow  npon  abscess  in  connection 
with  strumous  glands,  and  are  often  very  intractable. 
The  plans  of  treatment  available  vary  greatly  according 
to  the  nature  of  each  case.  Often  there  is  not  free  vent 
for  the  discharge,  and  then  the  aperture  may  be  enlarged 
or  the  abscess  cavity  more  carefully  drained.  More 
commonly  the  persistence  of  the  sinus  depends  upon 
the  unhealthy  action  going  on  in  the  part.  In  such 
cases  injections  of  carbolic  acid  lotion  or  of  weak  solu- 
tions of  iodine  or  of  nitrate  of  silver  may  be  tried,  and 
this  may  be  combined  with  gentle  pressure  by  a  well- 
adjusted  pad  in  cases  where  such  compression  is  possi- 
ble. If  several  sinuses  near  together  are  connected 
with  one  another  by  undermined  integument,  the  skin 
so  affected  may  be  slit  up  and  the  cavity  dressed  from 
the  bottom.  Iodoform  ointment  is  an  excellent  appli- 
cation in  these  and  like  cases. 

Often  the  defective  healing  depends  upon  undermined 
skin.  This  skin  soon  becomes  sodden  or  thinned,  and 
is  always  purplish  and  unhealthy  looking.  Under  such 
circumstances  it  should  be  without  doubt  destroyed,  as 
has  been  repeatedly  advised.  This  destruction  is  best 
effected  by  the  actual  cautery.  It  is  much  more  ready, 
more  certain,  and  on  the  whole  less  painful  than  the 
treatment  by  potassa  fusa  and  other  caustics.  Excision 
of  the  undermined  skin  is  never  desirable.  In  all  these 
cases  of  intractable  suppuration  and  persistent  sinuses 
one  measure  should  always  be  observed,  and  that  is  to 
kept  the  part  at  rest.  This  applies  especially  to  mis- 
chief in  the  cervical  region.  Few  parts  of  the  body  are 
more  constantly  in  movement  than  is  the  neck;  and  yet 
without  taking  any  precautions  to  insure  that  rest  that 
is  so  indispensable,  the  surgoon  is  surprised  that  a  sup- 
purating district  in  a  child's  neck  declines  to  heal  in 


l8o  THE  TREATMENT  OF 

spite  of  all  his  treatment.  In  any  case  where  the  heal- 
ing process  is  disposed  to  be  tardy,  I  apply  a  stock  of 
gutta-percha  to  the  neck,  and  insure  an  absolute  quiet 
for  the  inflamed  and  irritated  parts.  This  stock  is 
readily  made,  and  should  have  its  fixed  points  above  at 
the  lower  jaw  and  occiput,  and  below  at  the  chest  and 
shoulders.  If  it  be  well  moulded  over  each  shoulder  it 
merely  requires  a  circular  band  of  strapping  to  maintain 
it  in  position.*  Padding  should  be  applied  at  all  points, 
where  the  edge  of  the  stock  comes  in  contact  with  the 
skin,  and  if  this  be  done  the  child  can  wear  the  apparatus 
night  and  day  for  weeks  without  much  inconvience.  It 
can  be  readily  removed  when  needed  to  dress  or  inspect 
the  wound.  I  have  been  surprised  at  the  immense 
improvement  that  has  followed  upon  the  use  of  this- 
simple  collar  of  gutta-percha  in  cases  that,  before  its  use, 
had  appeared  most  intractable,  and  feel  sure  that  its; 
more  extended  application  would  do  away  with  a  good 
many  of  the  more  obstinate  cases.  Sometimes  they 
may  be  sore  at  points  where  the  stock  should  press ;  in 
such  cases  the  head  and  neck  should  be  fixed  by  the 
apparatus  advised  by  Sayre  for  cervical  spine  disease, 
the  trouble  of  applying  such  an  apparatus  being  well 
repaid  by  the  good  result  that  follows. 

Scars. — The  treatment  of  the  unsightly  cicatrices 
that  often  follow  after  scrofulous  gland  disease  demands 
but  a  brief  notice  in  this  place.  Any  nipple-like  pro- 
jections that  exist  about  the  scar  may  be  snipped  off. 
Prominent  bars  and  ridges  often  disfigure  the  cicatrix, 
and  these  may  sometimes  be  removed  with  scissors, 
and  some  improvement  thereby  effected  in  the  appear- 
ance of  the  part.  Now  and  then  a  scar  that  is  non- 
adherent, but  that  is  unsightly  from  its  persistently 
purplish  color  or  its  irregularity  of  surface,  may  be  con- 
vienently  excised,  provided  that  the  adjacent  parts  be 

*  I  first  take  a  rough  model  of  the  neck  with  a  sheet  of  paper,  and  then 
cut  the  stock  out  of  a  piece  of  gutta-percha,  such  as  is  used  for  making 
splints.  This  is  placed  in  warm  water  until  it  is  soft  enough  to  be 
moulded  to  the  neck.  A  slit  here  and  there  along  the  edge  of  the  stock 
is  needed  to  ensure  a  good  fit. ,  The  vertical  free  borders  of  the  stock 
should  overlap  in  front  in  the-  middle  line  of  the  neck 


SCROFULOUS   LYMPHATIC   GLANDS.  l8l 

perfectly  sound  and  the  patient  in  good  health.  By 
this  means,  if  good  healing  occurs,  a  clean  white  linear 
scar  takes  the  place  of  the  unpleasant  scrofulous 
cicatrix. 

The  presistence  of  many  of  the  scars  in  struma  and  a 
good  deal  of  their  unsightliness  depend  upon  their  being 
adherent  to  subjacent  parts.  To  remedy  the  deformity 
produced  by  this  class  of  cicatrix,  Mr.  William  Adams 
has  proposed  a  very  ingenious  operation.*  The  steps 
of  the  operation  are  as  follows: — ist.  All  the  deep 
adhesions  of  the  scar  are  divided  subcutaneously  by  a 
tenotome  introduced  beyond  the  margin  of  the 
depressed  tissue.  2nd.  By  a  little  manipulation  the 
cicatrix  is  everted,  or,  as  it  were,  turned  inside  out,  so 
that  the  scar  tissue  is  made  very  prominent.  3rd.  Two 
hare-lip  pins  are  passed  at  right  angles  to  one  another 
through  the  base  of  the  cicatrix,  so  as  to  maintain  it  in 
its  raised  and  everted  position.  4th.  On  the  third  day 
the  needles  are  removed,  and  the  scar  tissue,  now 
swollen  and  succulent,  is  allowed  to  return  to  the 
proper  level  of  the  skin.  Speaking  from  a  knowledge 
of  cases  that  were  operated  upon  several  years  before 
the  publication  of  his  paper,  Mr.  Adams  asserts  that  the 
depression  of  the  scar  does  not  recur,  and  that  the 
appearance  of  the  part  is  considerably  improved. 

*  British  Medical  Journal  vol.  i.  1876,  p.   534. 


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